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.

How To Throw A Hookah Party

Many people who like to smoke the shisha on their spare time also want to share it with their friends. Here is a little instructional article on How to Throw a Hookah Party for you and a handful of friends.

Hookah Party

When you decide that it’s finally time to throw your own hookah party, there are a few things you are going to need to keep in mind:

Plan a Hookah Party

The happening hookah party is the way to go while hosting a themed party.

Do
• Ask a friend who is making a trip to Mumbai to get you some exotic tobacco flavours
• If you are hosting the bash on a terrace, throw around charpoys instead of regular chairs
• Make the menu predominantly non-veg and set up a barbecue if you have space

Don’t
• Go for very loud music. Soft Arabian tracks is best suited for the theme
Hookahs have long been elevated to status-symbol status, moving out of smoky sanctums into public hot spots all over the country. Its allure is more than just about regal attitude, it is considered to be a less harmful alternative to smoking.

“Hookah is in vogue and getting hooked to hookah is better than smoking cigarettes. It is not very harmful and adds loads of attitude too. The variety of flavours make it my favourite,” says Somik Roy, a second-year student and regular at the city’s hookah bars.

But if you are not very fond of the crowded dance floors, try throwing a hookah party of your own.

Hot spot

The shisha (which means hookah in Arabic, all loaded up and ready to light) will emit a lot of smoke, so it is always advisable to have a hookah party in an open space unless you have proper ventilation facilities. A terrace or a lawn is the best site to fire things up.

Throw around some charpoys instead of tables and chairs. And if you want to be more adventurous, dress the waiters up in Arabian attire.

Flavour facts

There are three types of hookahs — the “grandfather” variety which are several feet tall, the medium-size version that we see everywhere and the small one where you can inhale tobacco directly from the pot. If you are having a hookah party at home it is advisable to use the standard size, as it is not space consuming.

You will be spoiled for choice when it comes to flavours of tobacco. Pick from flavours like peach, apricot, cola, mint, jasmine and strawberry. However, unusual flavours are also catching on. “There is a growing fan following for milk, cappuccino and caramel flavours. Vodka and cocktail flavours are also quite popular,” says Sovon Mukherjee, manager, Shisha Bar.

Flavoured tobacco is brought in from Mumbai, so you should plan your party well in advance as you may have to make a trip yourself. However, normal hookah tobacco is readily available in Calcutta. If you are hell bent on the fancy flavours but don’t have sources in Mumbai, you’ll have to stick to Shisha Bar on 22 Camac Street or Fusion at The Golden Park where you will find everything at your disposal.

Menu matters

Anything non-vegetarian goes down best with the aromatic puffs. Having a barbecue alongside will only add authenticity to the ambience. The smell of roasted meat and the sight of glowing charcoal can take you anywhere from Egypt to Afghanistan.

Indian and Chinese starters could work, but it is Lebanese food that is in vogue. Names like Tagin (Lebanese-style baked fish), pita sandwiches and Fathous (a Lebanese salad) may sound alien, but when they are ready and placed before your guests, they are sure to fly off the plates.

Tune talk

You will have to give loud music a miss for one night. The music has to be soft and soothing, creating a hypnotic effect, helped by the clouds of steam and smoke being let out around the puff party.

In true lounge style, the dance floor is not the centre of attraction. Just sit back and relax.

Arabian music is best suited for the theme of the party. Tracks like Habibi, Nari nari and Al husna are surely going to leave you puffing for more. And if all else fails to soothe your nerves, the original version of Sting’s Desert rose will never let you down.

But if your guests get a hookah high and insist on showing off their dancing prowess, switch over to some Arabian fusion music. It will not disturb the theme of the party and will also provide ample scope for a jig.

“You will always have some people who will want to hit the dance floor. So it is better to keep some hip-hop tracks ready. But it is trance which is going to rule the revelry,” says DJ Girish of Shisha Bar.

Some other things to check out are:

Display some hookah art

Check out some hookah-related warnings

Print out our simple 13 steps to setting up a hookah for your less-smart friends

and Make Some Turkish Coffee to with this secret recipe

Avoid The Hookah And Save Your Teeth

When you are looking at health-realted articles about hookah use, you may find a great deal of differing information. Doctor’s still aren’t sure about the effects of smoking the Shisha, but here is one thing I found online that can give you a worst-case scenario:

Avoid The Hookah And Save Your Teeth

Smoking a hookah also known as a water pipe is becoming an increasingly trendy menu item in Mediterranean restaurants, cafes and bars. People should be warned to “skip this course” according to a study that appeared in the November issue of the Journal of Periodontology.

Researchers found that the impact of water pipe smoking is largely the same magnitude as that of cigarette smoking. The prevalence of periodontal diseases was 30 percent in water pipe smokers, 24 percent in cigarette smokers and eight percent in non-smokers.

“Research from this study shows that the relative risk for periodontal disease increased by 5-fold in water pipe and 3.8-fold in cigarette smokers compared to non-smokers,” said Kenneth A. Krebs, DMD and AAP president. “Even though the smoke is filtered out by water, inhalation of toxic substances is similar to or even greater than that of cigarette smoking.”

“Many people are mislead in believing that water filters out the toxins and that nicotine is reduced in water pipe smoking,” Krebs. “Not only does water pipe smoking include the same substances as cigarette smoke such as carbon monoxide and tar, tobacco used for water pipe smoking contains two to four percent nicotine verses one to three percent for cigarettes.”

Researchers found increased levels of nicotine and cotinine in plasma, saliva and urine, supporting that water pipe smoking affects the periodontal tissues in the same way as cigarette smoking. “This study provides convincing evidence supporting the role of tobacco smoking as a risk factor for periodontal disease,” said Krebs.

“Although the precise mechanisms of action of tobacco smoke are not well understood, it seems highly likely that the periodontal bone is one of the most susceptible tissues,” said Krebs. “This hypothesis will be further tested by investigating the periodontal bone height levels of various tobacco smokers in the presently studied population.”