Is Smoking a Hookah Bad for Your Health?

Below is an interview with Dr. Thomas Eissenberg, associate professor, department of psychology and Institute for Drug and Alcohol Studies at Virginia Commonwealth University:

Q: Is it true that hookah smoke is better than cigarette smoke because it’s filtered through water?

A: Unfortunately, there are no data by which we can compare directly the health effects of smoking tobacco using a waterpipe with those of smoking tobacco cigarettes. The necessary studies have not (yet) been done.

However, we do know that the smoke produced by a waterpipe contains some of the same carcinogens as in cigarette smoke, as well as substantial amounts of carbon monoxide (implicated in cigarette-caused cardiovascular disease.)

The one study that addressed the issue provided no evidence that the water influences the amount of carcinogens, carbon monoxide or heavy metals present in the smoke produced by a waterpipe.

Q: Is there an equal amount of nicotine in hookah and cigarettes? Do you happen to have any of the statistics on how much nicotine and carbon monoxide there is in hookah?

A: Waterpipes are used for periods that can last for 30-45 minutes, while a single cigarette is smoked for about 5 minutes. The average puff on a waterpipe produces about 500 ml of smoke, while the average puff on a cigarette produces about 50 ml of smoke.

A hookah smoker can take about 100 puffs when s/he uses a waterpipe (i.e., in a single 30-45 minute session) while a cigarette smoker takes about 10 puffs.

Waterpipe use episode can involve some 100 puffs of 500 ml of smoke each, or 50,000 ml of smoke (or 50 liters). A cigarette use episode can involve some 10 puffs of 50 ml each, or 500 ml (0.5 liters).

With all this in mind, you wouldn’t be surprised to hear that there is more nicotine in waterpipe smoke, and you are right – one study shows that the smoke form a waterpipe, produced as though a human were smoking it, contains about 2.96 mg nicotine. Similar studies with cigarettes show that cigarette smoke contains about 1.74 mg nicotine.

The difference is not as big as you’d think, given the huge difference in volume of smoke produced, ml for ml, there is less nicotine in waterpipe smoke than in cigarette smoke, though there is MORE nicotine in the smoke produced from a single waterpipe use episode (30-45 minutes) than is produced from a single cigarette (5 minutes).

Of course, the nicotine in tobacco smoke isn’t what causes cancer and cardiovascular disease. For that, you have to look at “tar” (actually, nicotine free, dry particulate matter, or NFDPM) and carbon monoxide (CO.) The same studies show that waterpipe smoke contains 802 mg tar compared to 22.3 mg for cigarettes, and 145 mg CO, compared to 17.3 mg for cigarettes. Thus, a single waterpipe use episode (lasting 30-45 minutes) can yield slightly more nicotine than a single cigarette, and about 36 times the tar and 8 times the CO.

Q: How frequently and how long would each hookah smoking session have to be, before you see dangerous side effects or diseases?

A: Nobody knows the answer to that question. I don’t claim to be a cancer expert, but I have heard some say that the action of carcinogens may be based more on probability than dose. That is, a single molecule of carcinogen has an infinitesimal, but non-zero probability of inducing cancer in the cell(s) that it contacts.

If this statement is true, it would explain the well-known dose-relationship between smoking and cancer, as well as the fact that there are rare cases where people smoke all their lives and do not die of smoking-related disease.

Also, if the statement is true, it suggests that ANY carcinogen intake carries some risk, however small, and that even a single waterpipe use episode or single cigarette could have a non-zero probability of inducing cancer. We would do well to avoid carcinogen inhalation whenever we can.

Q: Is hookah just as addictive as cigarette smoke?

A: I believe that there are two components to tobacco smoking, physical dependence on nicotine and, for lack of a better phrase, a “psychological dependence” on tobacco use (potentially an associative, or learned, phenomenon1,2).

There is enough nicotine in waterpipe smoke and waterpipe users to support physical dependence, and the data suggest that some waterpipe smokers show the hallmarks of dependence (i.e., withdrawal when the stop, behaviors to avoid stopping, failure to quit despite known health risks, etc).

Also, and perhaps more important for the occasional user, there are many of the requirements for a psychological dependence – an elaborate preparation ritual and distinctive cues (smell, taste, environment) that are paired with numerous potent reinforcers that include pharmacologic (nicotine), biologic (rest, relaxation), and social (companionship) stimuli. Given these facts, waterpipe use is likely to be AT LEAST as addictive as cigarette smoking.

Q: If it is just as bad for you as regular cigarettes, why do you think many young people (18 and younger) enjoy smoking hookah?

A: I don’t know if smoking tobacco using a waterpipe is as bad for you as “regular cigarettes”, and I won’t say that it is or that it isn’t. People probably enjoy it for the reinforcers that I just mentioned – the pleasurable stimulant effects of nicotine, the relaxation and resting waterpipe use promotes, and the social facilitation that can accompany it.

Add to that a pleasant aroma, sweet flavor, and room temperature smoke that can easily be inhaled without coughing, as well as a myth that the smoke is not dangerous, and avoiding a waterpipe that is offered by friends becomes quite difficult.

Q: Are there any other proven side effects to long-term hookah smoking, such as infertility?

A: A variety of studies are emerging that link waterpipe use to infectious disease transmission and dental problems. There are heavy metals in waterpipe smoke (perhaps from the charcoal) that may also be associated with some health risks.

I am uncertain of the long-term health effects of inhalation of arsenic, cobalt, chromium and lead3, but I know I would prefer to avoid inhaling those elements.

Q: What unique risks were you referring to when you mentioned the adverse effects of smoking from the heavy-metal pipe?

A: It’s not the pipe that is heavy metal, but the fact that heavy metals have been found in the smoke produced by a waterpipe, in concentrations far above those seen in cigarette smoke.

Q: Is there any additional information you would like to share?

A: The important issue for me is not whether waterpipe smoking should be “banned.” I am on record as opposing bans of psychoactive substances, at least when other approaches are likely to be more effective at reducing addiction, disease and death.

The important issue for me is to know what the risks are, so that folks can make an informed decision about their potentially risky behavior. Being enticed by a sweet flavor, a social atmosphere and a *myth* about water “filtration” does not constitute an informed decision.

The beginning of informed decision-making includes the knowledge that the sweet flavor is accompanied by carcinogens, heavy metals, and lethal carbon monoxide, and that the behavior has been associated with cancer and cardiovascular disease.

What Dr. Herman Kattlove, a medical editor at the American Cancer Society, has to say about hookah smoke and its effect on the human body:

Young people are most sensitive to becoming addicted to nicotine. Nicotine is an addictive substance, so it’s advertised to college students. For this reason, hookah smoke can kick start a smoking habit.

Hookah has been banned for those who are 18 and younger. For most young Americans who smoke hookah, their heart rates will go up and breathing will become labored.

There are very few solid U.S. studies that have been done on the effects of hookah smoke. Most studies are done in Egypt and Middle Eastern countries. Israeli smokers were surveyed and about 90 percent of them said hookah smoke is bad for you.

In the Middle Eastern studies, hookah smoke has the same amount of nicotine and tar particles as cigarette smoke. There are even unique poisons and evidence of lead arsenics that come from smoking out of the hookah’s heavy metal pipe. The amount of carbon monoxide is also very high and related to heart attacks. Secondhand smoke contributes to breast cancer and has been linked to lung cancer.

One session of hookah smoke (approx. 45 min.) is the equivalent of smoking one pack of cigarettes per day. The blood levels and genetic changes of the bronchial tubes and chromosome changes of hookah and cigarette smokers are about the same. There is just as much damage from both.

Hookah is a recent phenomenon, so there is not a lot of evidence to support these findings.

Hookah Lounge Etiquette and Smoking Technique

Hookah Lounge Etiquette and smoking tips

By being aware of this, you may have confidence to travel anywhere in the world and use a hookah.

Be aware that not all the places listed in the directory are hookah lounges exclusively. Some are coffee shops or restaurants with Middle Eastern cuisine and flair, and supply shishas as an aside. They cater to Middle Eastern clientele and are as intimate as a livingroom with a group of regulars, and YOU, as a newcomer, are expected to be on your best behavior. Respect the culture. You know a place is good when you see Middle Eastern people present, don’t drive them away. Many establishments rely on regulars and have close ties with them. (“We used to go there, but it has been overrun by disrespectful kids. They’ve ruined it for the rest of us.”) As a side note, don’t let your thoughts of current world events be translated to other customers. It is best to avoid this topic. We all wish the best for the future.

In general, many hookah lounges are very classy and plush places with unique decor.
Keep with the vibe, dress nicely, be respectful and don’t be a loudmouth.

If you show up in shorts, flip-flops, an ICP shirt and a backwards baseball cap, and you’re a loudmouth, everyone will think you’re an A-H and you’ve ruined the vibe for everyone. You’ll be like a cockroach in the rice bowl. On the other hand, some places cater to you rowdy idiotic slobs and puke-reeking fashion disasters as long as you have money to blow. Do yourself and the industry a favor, keep up the high standards. Since this phenomenon is still rather young, we still have a chance at shaping its destiny. The media is already trying to pigeon-hole the hookah lounge clientele, so let’s perpetuate the favorable reputation and do it RIGHT.

Hookah Lounge owners: I suggest “DRESS CODE ENFORCED” and don’t play Beastie Boys on the stereo.

Some small restaurants may be eventually driven to post “Shisha with meals only.” OBLIGE THEM. The experience will be vastly improved!
Fancy Hookah Bar
It seems that everyone’s missing the point already, thinking that just merely showing up to one of these places makes you cool. Well WAKE UP! Don’t be a kook! Be a pro and dress like one after we help to show you how to ACT like one. Part of what makes shisha smoking so cool is the mastery of the people involved. Don’t dilute the coolness factor.

Hookahs belong on the floor and not on the table, because it is an object of service. Imagine the notion of “putting someone on a pedestal.” This is along the same idea, and the shisha is an item of much lower rank, if you will. Traditional establishments will still adhere to this rule, while some hookah lounges are placing the hookah on the table for everyone to enjoy. Not very authentic, but it does celebrate the hookah. Smaller hookahs on a table are more convenient, as you can imagine, and sometimes this is the only option.

Now some hard rules and tips to stop kooks in their tracks.

Never light your cigarette from the hookah coals, it’s considered VERY bad manners.

Use the hookah hose with your RIGHT hand. The left hand is considered unclean in many countries.

When sharing a hookah and you’re done smoking for the moment, place the hose down on the table for the next person to pick up. Don’t pass it directly. A variant of this is if you must pass, use the RIGHT HAND with the tip facing towards you, not the recipient. Turn the hookah toward the recipient or have the hookah placed in a neutral position to prevent tipping. Sometimes the hose is so long that this isn’t an issue, or a rotating hookah may be used.

Use the tongs to occasionally tap the coals in the tray on the stem to remove ash and keep the coals hot. Replace the coals to a different position on the bowl.

And now for the obvious: On multiple hose hookahs, those not smoking for the moment should plug their mouthpieces with a finger so that the person smoking doesn’t suck air.

Many people suggest using punctured foil on top of your bowl underneath the coals. DID YOU KNOW THAT EXCESSIVE ALUMINUM IN THE BODY CAUSES ALZHEIMER’S? Smoking from household aluminum isn’t good for you anyway, there are also bonding agents that give off fumes. Don’t be afraid with OCCASIONAL smoking, but don’t make it a habit; don’t use household foil on your personal hookah. There is foil available made especially for hookahs, or use a screen meant for hookahs. The latter is recommended, but your bowl will last much longer with foils if the holes are done correctly.

With the tongs, move the coals around the screen occasionally to allow for even burning of the tobacco throughout the session. The center of the bowl should be the ending place the coals should be concentrated, but this doesn’t matter much.

There is no urgency or competitiveness when smoking a shisha unlike sharing smaller pipes. The bowls last a long time, and this is a leisurely activity. Enjoy it. It is recommended that one shisha be shared among no more than three people. Some lounges enforce the two people per shisha rule.

Don’t take too many photos in a hookah lounge, it disturbs the atmosphere. (“Hookah, yaaayy, wooo!!”) In fact, you might get some dirty looks depending on where you are.

Don’t cause or contribute to a commotion. Shisha smoking is a quieter activity but still may be social without being disturbing to others.

Don’t smoke cigarettes unless ashtrays are provided. Take the hint – If there are no ashtrays, then cig smoking is probably not allowed, but ASK FIRST before lighting up. They might have ashtrays behind the counter for you OR they might say no cigarette smoking is allowed in certain areas. Respect people’s wishes and don’t argue. Chances are that in the Middle East, if you don’t see others smoking cigarettes then the activity is frowned upon.

DO NOT use the coal tray for your cigarette ashes. That’s a TOTAL kook move.

With respect comes respect, and this process is initiated with the successful mastery of the shisha and social manners in the presence of other masters. When you have mastered the shisha and know fully and demonstrate the social manners associated with it, you may have confidence in enjoying the shisha anywhere in the world and in teaching others so that the proper etiquette is perpetuated.

Hookas – The Ancient Art of the Middle East

Hookas – The Ancient Art of the Middle East

Source: Antika, The Turkish Journal of Collectable Art, February 1986 Issue: 11
By: G?ºnay Gercek

Throughout the ages, human beings have shown a special interest in intoxicating substances, and derived pleasure in delving into other worlds in their experiments with the new materials of this type which they have discovered. For this purpose, they have felt the need for a variety of devices. One of these devices is the hooka, also known variously as hookah, water pipe and hubby-bubbly. hookas were first used five centuries ago and they are a device still employed today-though not very commonly. Research conducted indicates that they were first used in India.

Born in India, the hookas spread to the countries of the Near East, East Asia, Egypt, Arabia, Persia, North and East Africa, and all the way to the Ottomans. In each country it has been subjected to various changes, and finally assumed its present form. Called various names in each country where it is employed, the term is in fact of Persian origin.

Since very early times, the Indians have been raising hemp and employing such plants as medicines. Originally only its seed was used to obtain cannabis oil, but with time, the qualities of the plant’s leaves were discovered and they were exploited in the production of intoxicants, thus leading to the discovery of hashish.

Thus drug was originally employed as a powerful anaesthetic, but with the admixture of other plants and spices, a sort of paste was produced and by eating it they made it a pleasure and habit to delve into a dream world. Not being satisfied with this, they attempted to obtain the drug in its pure form, for which purpose they felt the need for various devices. It was the hookas which arose as the natural result of those desires.

The precursor of the hooka is the narcil, a type of coconut which grows commonly in India. The inner meat of this nut was removed and the shell was pierced, following which a straw was placed inside, the resulting “device” being the first simple form of the modern hookas. It was from the name of this nut that this primitive device was also called narcil.

Subsequently the device reached Egypt by various routes where its form was somewhat changed. For example, the body was made from a gourd rather than from a coconut shell.

Although the name narcil was still adopted, owing to differences in pronunciation the /?ß/ sound was read as a/g/ and thus the word became entrenched as nargile, or hookas.

The Persians saw this device and liked it, and they developed it even further, adding a number of parts. The body, which originally consisted of a coconut shell and then a gourd, they made into a porcelain flask, and instead of the straw, they added a soft and flexible part which resembled a hose and which was mucn more practical. They called this part marpic, which in Persian means “snake coil.”

Around that time, tobacco was discovered and with the beginning of its use as an intoxicant, the Persians experimented with the substance. For this purpose, they developed a tray to be placed above the body which would hold the tobacco. Made of bronze to ensure its strength, this tray was given the name ser, which means “head”. It was also the Persians who first made use of the type of tobacco known as t??mbeki.

The Arabs also made use of the hookas. Nevertheless, they employed it in its primitive form, which is to say, using the coconut shell. Hookas with bodies of coconut shell, long wooden heads, set on iron stands and with hoses sewn from thick cloth were in use in Syria and the Yemen.

The arrival of the hooka among the Ottomans took place at quite a late stage. Although there is no specific date indicated, it would be correct to state that it was used after the introduction of tobacco into the country. At this point I believe there is value in taking a look at the establishment of coffee houses in our country.

There were no hookah bars among the Ottomans until the reign of Sultan S?ºleyman the Lawgiver. We learn from the history of Pe?ßevi that one was first opened in 1554. According to this history, someone by the name of Hakem from Aleppo and a nobleman by the name of _ems from Damascus opened a shop at “Tahtelkale” (modern Tahtakale, presently a commercial district of Istanbul), thus laying the foundations for the first coffee houses. Initially places frequented by people referred to as the “rabble,” coffee houses subsequently became places where doctors of law, theologians, and the upper classes met and talked while drinking coffee. With time, the quality of these places fell and became increasingly degenerate, and being regarded as haunts of idlers, they were subjected to vigorous prohibition during the reign of Murat III.

This prohibition continued up until the reign of Mehmet III, but since people could not be prevented from attending such places, even if only in secret, the prohibition was abolished at the end of his reign. It was during these years that tobacco entered the country. Tobacco, arriving from England in ships, was first sold as a drug, but with the subsequent discovery of its intoxicating properties, it began to be used exclusively for that purpose, since its consumption that way was more enjoyable. Thus, on the basis of all these facts, it would not be wrong to state that the use of hookass took place in the 17th Century.

The Ottomans made hookas according to their own tastes, and made them more useable. For example, above the “head” they placed a bowl the “head” they placed a bowl of baked clay and they added a mouthpiece to the portion of the hose which entered the mouth. The body they made of glass, crystal, rock-crystal, porcelain and even silver. To the heads, which they made of brass and silver, they added a pipe holder which were decorated at their extremities with plant motifs and carvings.

There were considerable differences in terms of manufacture and decoration between the hookas employed by the ordinary people (the “commoners”) and by the upper classes (the “greats”). In particular, the jewelled hookas decorated with precious stones and manufactured to order for the palace are worthy of acclaim.

The hookas used among the people were quite plain, while some were manufactured with two or three hoses and used by several people simultaneously.

For the date of use of hookas, whose employment began during the Ottoman period, it will be helpful to mention the entry into the country of glass, on account of the use of that material in the bodies. Glass gained particular value and great developments took place in the glass industry in the 16th to 18th Centuries. Indeed, the renown of glassware manufactured in Istanbul extended outside the borders of the country.

Glassmaking assumed the aspect of a branch of the arts during the reign of Murat II, and during the reign of Mustafa III, it was taken under the protection of the Palace. Nevertheless, since crysatl could not be obtained by chemical means in our country during this period, all the valuable Palace glassware of the time was made to order in Bohemia.

Towards the end of the 18th Century, the manner of obtaining cut crystal by chemical means was discovered. Thanks to craftsmen who were brought from abroad beginning with the reign of Mahmut I, its manufacture in our country began and crystal were of great beauty and desbign was produced.

During the reign of Selim III during the 19th Century, a Mevlevi by the name of Mehmet Dede set up a workshop in Beykoz, a place where the famous Beykoz glassware was made. Though following these workshops, which from time to time ceased activity and from time to time were open under the protection of the Padishahs, a glass factory was established at Pa_abah?ße in 1899 by a Jew by the name of Saul Modiani, it was unable to compete with the glassware being then imported from Europe and halted production. The first glass factory in the modern sense was established at Pa_abah?ße on the orders of Atat?ºrk in 1934 during the Republic period. The most beautiful of the hookass used during the ottoman period were those made at the Beykoz workshops.

To give a complete definition of a hooka, one could say that it was a device which permitted the smoking of a type of tobacco known as t??mbeki by means of eliminating excess nicotine by passing the smoke through water. T??mbeki or Persian tobacco, is a type originating in Iran and which is used only in hookass. The leaves and stalks of this tobacco are picked together, and after being subjected to special processing is made usable. T??mbekiis not chopped like tobacco, but is broken up by hand. A good quality of t??mbeki was at one time grown in our country in the regions of Hatay and Konya.

The use of hooka and the smoking of tombeki consists of several sections; the pipe, the head, the body, the hose, and the mouthpiece.

The pipe, is outside the hooka located at its highest pint, and is a plate with holes in it made of potters clay. Since the tobacco was also burned here, this was also referred to as ate_lik or fire pan.

During the Ottoman period, pipe making assumed the aspect of an important branch of the arts, and there were even special pipe markets in Tophane. Good quality potter’s clay the color of coral was worked her, and beautiful pipes of every size were made here. It is possible today to see in the Ankara Ethnographic Museum, examples of pipes remaining from ages past which are gilded, decorated, and glazed.

The head was a piece between the pipe and the body. It was made of hard materials in order for it to be resilient. The upper portion was shaped so as to hold the pipe, and this part was decorated with carvings. The head was general made of brass, coper, or bronze. Very special ones were made of silver. Near the point where these are connected to the body, there is a nipple-like protrusion onto which the hose was attached.

The hooka bottle, or body, most often was in the form of a pitcher with a narrow neck and broad belly. Though originally made of a coconut shell and even from gourds, these were subsequently made of glass, china, ceramics, porcelain, rock-crystal, and metals, including silver. The decorations on the hookas bottles made of crystal and cut glass during the Ottoman period are separate masterworks of art in themselves. Nowadays, only plain, ordinary glass is employed, and no attention is given to decoration.

The hooka bottle contains water, and there is a thin hose descending from the pipe. Thanks to this hose, the smoke coming in is cleaned somewhat in the water and at least some of the nicotine from the Persian tobacco is eliminated. The hose is a flexible tube capable of being bent every which way and is attached to the nipple-like protrusion on the upper portion of the head connected to the body. This serves to conduct the smoke cleansed in the hookas bottle to the mouth.

The most beautiful of these hoses were made in the Ottoman period, and in the 19th Century, their manufacture assumed the aspect of an art, at that time, there was even a special market for them alongside the Egyptian Bazaar, at the approach to the district of Mahmut Pa_a. Here, colourful hookas hoses were manufactured from sheepskin leather. The leather was cut in strips two fingers wide, and after being glued, these were wrapped around an iron rod then tied with thin wires. After drying, the rod was pulled out, thus producing the hookas hose. Since this leather did not keep its resiliency for long periods of time it is difficult to find hookas hoses nowadays. Today, they are made entirely of plastic and they are decorated with various strips of cloth or velvet.

The mouthpiece was attached to the end of the hose and was the part placed in the mouth and sucked upon. In the past, only amber was used to make these mouthpieces, and their manufacture was a separate art. The part of the mouthpieces, and their manufacture was a separate art. The part of the mouthpiece actually placed in the mouth was a thumb-shaped knob. The best mouthpieces were in the form of large sweet water grapes, and were given the name “goat’s teat”. These thickened towards the middle, tapered off towards the end, and were made of amber. At one time, the mouthpieces made of reddish amber were the most esteemed. Nowadays, these mouthpieces do not receive the importance they deserve, and plastic has assumed the place of amber.

Though hookas are used today, they have lost their former importance. Since their use, preparation, and transportation are not very practical, they are used by very few persons for pleasure. Nowadays, one sees them being smoked with pleasure in shoreside coffee houses along the water.