Table of Contents
- Key Points
- What Is Hookah?
- Who Uses Hookah?
- How This Information Was Compiled
- Health Effects of Hookah Smoke: Key Findings
- Secondhand Hookah Smoke: A Hidden Danger
- Public Health Implications and Policy Recommendations
- Study Limitations
- Recommendations for Patients
- Frequently Asked Questions
- Source Information
Key Points
- Hookah smoke contains cancer-causing chemicals, delivers significant nicotine, and harms lung function just as much as cigarette smoke.
- A single hookah session lasting 20 to 80 minutes can expose a smoker to as much smoke as 100 or more cigarettes.
- A meta-analysis of four studies found hookah use equivalent to smoking 2 to 10 cigarettes per day, enough to cause addiction.
- Secondhand hookah smoke is at least as harmful as secondhand cigarette smoke; one study found a one-hour session generates toxicants equal to 2 to 10 cigarette smokers.
- Hookah bars should not be exempt from smoke-free laws, and hookah tobacco should be taxed, age-restricted, and regulated like other tobacco products.
What Is Hookah?
Hookah smoking, also known as waterpipe smoking, is a method of smoking tobacco that has been practiced for centuries in the Far and Middle East. The process involves burning tobacco, passing the smoke through a water-filled bowl, and then inhaling it through a long hose.
Waterpipes go by many different names around the world. You may hear them called:
- Hookah
- Shisha
- Boory
- Goza
- Narghile or nargile
- Arghile
- Hubble bubble
Today, the most common type of tobacco smoked in a waterpipe is called shisha or Maassel. This tobacco is sweetened and flavored with options like apple, mint, cherry, or even cappuccino.
Many people assume that because the smoke passes through water, it must be cleaner or safer. This is simply not true. The water does not filter out the harmful chemicals in tobacco smoke.
Who Uses Hookah?
Waterpipes are most commonly used in China, India, Pakistan, and the Eastern Mediterranean Region. However, over the years leading up to this report, hookah has been gaining popularity in the United States, particularly among college students and young adults. Several studies cited in the original fact sheet document this growing trend among young people.
Hookah smoking is a social activity. It typically takes place in groups, and hookah bars have been opening with increasing frequency across the U.S., especially in college towns and urban areas. The American Lung Association estimated that there were approximately 200 to 300 hookah bars in the U.S. in 2006, and that number has likely increased since then.
The visibility of hookah bars has a direct impact on young people. In one study, more than one in five high school students (20.9%) first learned about hookah simply by seeing a hookah bar in their community.
Hookah use is far from rare among teens. Among high school seniors, 17% reported having smoked hookah in the past year, according to the Monitoring the Future survey.
Another important pattern: many hookah smokers have also tried cigarettes or other tobacco products, and many currently use them. This suggests that hookah is often not a replacement for cigarettes but rather an addition to a person's overall tobacco use.
How This Information Was Compiled
The original article is a policy fact sheet published in March 2012 by the American Cancer Society Cancer Action Network (ACS CAN). Rather than being a single new study, it is an evidence-based review that compiles findings from dozens of peer-reviewed scientific studies on hookah smoking.
Researchers and public health experts reviewed the existing scientific literature on waterpipe use, including:
- Studies of hookah prevalence among college students and high school students
- Laboratory analyses of the toxic chemicals in waterpipe smoke
- Clinical studies measuring nicotine and carbon monoxide levels in hookah smokers
- Meta-analyses comparing lung function in hookah smokers versus cigarette smokers
- Public health surveys and surveillance data from national and state agencies
This type of review is important because it gathers evidence from many different research groups and combines it into a single, reliable picture of the health risks. When multiple independent studies point in the same direction, the conclusions are much stronger than any single study alone.
Health Effects of Hookah Smoke: Key Findings
The most important message of the entire report is this: Smoking waterpipes, as well as breathing secondhand smoke from waterpipes, is at least as harmful as exposure to cigarette smoke. Despite what many hookah smokers believe — and several studies cited in the fact sheet confirm that many users think hookah is less harmful or less addictive than cigarettes — the scientific evidence clearly shows otherwise.
Cancer-Causing Chemicals in Hookah Smoke
Waterpipe smoke, like cigarette smoke, contains significant amounts of cancer-causing ingredients. These include:
- Arsenic
- Cobalt
- Chromium
- Lead
These heavy metals and carcinogens are inhaled directly into the lungs. Additionally, hookah smoke contains carbon monoxide (CO) in amounts equal to or greater than the levels found in cigarette smoke. Carbon monoxide is a poisonous gas that interferes with the blood's ability to carry oxygen, putting stress on the heart and other organs.
There is also a unique danger specific to hookah. Unlike cigarettes, hookahs use charcoal or wood cinders as the heat source to burn the tobacco. The combustion products from these heat sources add even more cancer-causing and heart-disease-causing agents to the smoke.
Lung Function Damage
A systematic review and meta-analysis of existing research found that waterpipe smoking has the same negative effect on lung function as cigarette smoking. This means damage to the airways and lung tissue that is typical of cigarette use also occurs in hookah smokers.
Nicotine and Addiction
Many people believe hookah is less addictive than cigarettes. The evidence says otherwise. Waterpipe smokers are exposed to sufficient doses of nicotine to lead to addiction.
A meta-analysis of four studies that assessed biomarkers of nicotine and tobacco smoke exposure in hookah smokers found that using a waterpipe was equivalent to smoking 2 to 10 cigarettes per day. This is a significant amount of nicotine exposure — enough to create a real chemical dependence.
Further supporting this finding, research shows that waterpipe smoke produces similarly increased blood nicotine levels and increases in heart rate as cigarette use. The body's addictive response to hookah is comparable to what happens with cigarettes.
A Single Session Can Equal a Pack or More
One of the most striking findings in the report is the sheer volume of smoke inhaled during a hookah session. A typical hookah smoking session lasts 20 to 80 minutes. During that time, a smoker may inhale as much smoke as that from 100 or more cigarettes.
This is because hookah smoking is not a quick, single inhalation like a cigarette. It involves repeated, deep draws over a long period of time, and the smoke is densely packed with toxins.
Disease Risks
The cumulative effect of all these exposures adds up to serious health consequences. Waterpipe smoke is associated with an increased risk of:
- Cancer (including lung and other cancers)
- Heart disease
- Lung disease
- Adverse effects during pregnancy
Additionally, because hookah is typically smoked socially, people often share the mouthpiece. This sharing increases the user's risk for communicable diseases, including infections that can be passed through saliva.
Secondhand Hookah Smoke: A Hidden Danger
It is not just the person smoking the hookah who is at risk. Breathing in secondhand smoke from waterpipes is at least as harmful as exposure to secondhand cigarette smoke.
One study found that during a typical one-hour hookah session, a waterpipe smoker likely generates ambient carcinogens and toxicants equivalent to that of 2 to 10 cigarette smokers. This means that other people in the room — friends, family members, employees at hookah bars, and other patrons — are breathing in a substantial amount of harmful chemicals, whether they are smoking themselves or not.
This finding is a critical reason why hookah bars should not be exempt from smoke-free laws. The health of everyone in the establishment is affected by the smoke in the air.
Public Health Implications and Policy Recommendations
Because the evidence is so clear, the World Health Organization (WHO) issued an advisory on waterpipe tobacco smoking in 2005. This advisory addressed the health effects of hookah smoking and made several key recommendations related to regulating hookah in a manner similar to other tobacco products. That advisory remained in effect at the time of this report and remains the scientific consensus.
The American Cancer Society Cancer Action Network (ACS CAN) supports the regulation of all tobacco products and the passage of strong smoke-free laws to protect people from the harms of secondhand smoke from all tobacco products. Specifically, the report makes the following policy recommendations:
- Hookah bars should not be exempt from smoke-free laws that prohibit smoking in public places, including workplaces, restaurants, and bars.
- Hookah tobacco should be taxed at an equivalent rate to cigarettes and other tobacco products, using a price-based approach with a minimum tax.
- Sales of hookah tobacco should be prohibited to minors under age 18.
- Waterpipe and hookah tobacco retailers and hookah bars should be subject to the same licensing requirements as retailers of other tobacco products in their jurisdiction.
- The Food and Drug Administration (FDA) should assert its authority to regulate hookah tobacco under the 2009 federal Family Smoking Prevention and Tobacco Control Act.
- Flavored hookah tobacco should be prohibited. Flavors like apple, mint, cherry, and cappuccino make the tobacco appealing, particularly to young people, masking the harsh taste of tobacco smoke.
- Questions about hookah use should be included on national and state-based surveys, particularly those targeting youth and young adults, to obtain information about the prevalence and patterns of hookah use that can be used to improve tobacco prevention and cessation efforts.
These policy recommendations reflect a straightforward public health principle: all forms of tobacco use are dangerous, and they should be regulated consistently. If a product is taxed, restricted by age, and subject to smoke-free laws when it is a cigarette, the same rules should apply when it is a hookah.
Study Limitations
It is important to understand what this type of report can and cannot tell us. The original fact sheet is a review of existing research rather than a single controlled clinical trial. This means it has some inherent limitations:
- No new original data: The conclusions are drawn from previously published studies, which vary in their methods, sample sizes, and quality.
- Limited long-term outcome data: Because hookah use has only recently become widespread in the U.S., long-term studies tracking hookah smokers over decades are not yet available. The disease risks are inferred from biomarker studies, lung function tests, and comparisons to cigarette smoking.
- Population differences: Studies included in the review were conducted in different countries and among different age groups, which may limit how directly the findings apply to every population.
- Self-reported data: Some studies relied on survey responses, and participants may not always accurately report their smoking habits.
- Evolving landscape: The number of hookah bars and patterns of use have continued to change since 2012, meaning some statistics (such as the 200–300 hookah bars estimate) may be conservative compared to today's numbers.
These limitations do not undermine the core message. The evidence that hookah smoke is harmful is consistent across many different types of studies, and the direction of the findings is clear. However, as with all scientific evidence, ongoing research will continue to refine our understanding.
Recommendations for Patients
If you are a patient or a parent of a teenager, this information has direct, practical relevance. Here is what you should know and what you can do:
- Do not assume hookah is a safe alternative to cigarettes. It is every bit as harmful — and in some ways, it is worse, because a single session delivers such a large volume of smoke.
- If you currently smoke hookah, you can become addicted. Hookah delivers nicotine at levels equivalent to 2–10 cigarettes per day. Addiction to nicotine is not limited to cigarette smoking.
- Talk to your children and teenagers about hookah. Nearly 1 in 5 high school seniors reported smoking hookah in the past year, and flavored tobacco products are specifically designed to appeal to young people. Do not let the sweet flavors fool you — these are tobacco products with serious health risks.
- Avoid secondhand hookah smoke. If you are in a hookah bar or at a gathering where hookahs are being used, you are breathing in harmful carcinogens. The same advice that applies to secondhand cigarette smoke applies here: if you can smell it, you are inhaling it.
- If you are pregnant or planning to become pregnant, avoid hookah completely. The report specifically identifies adverse pregnancy outcomes as a risk of waterpipe smoke exposure.
- Do not share hookah mouthpieces. Sharing increases the risk of communicable diseases transmitted through saliva.
- If you are trying to quit tobacco, discuss hookah with your healthcare provider. Nicotine replacement therapy and other cessation supports can help with nicotine addiction, regardless of the form of tobacco you use.
The bottom line is simple: Hookah is tobacco. Tobacco is harmful. There is no safe way to smoke it. Understanding the science behind this conclusion is the first step toward making healthier choices for yourself and your family.
Frequently Asked Questions
Is hookah smoking safer than smoking cigarettes?
No. Hookah smoke contains cancer-causing chemicals, delivers significant nicotine, and harms lung function just as much as cigarette smoke. A single hookah session can expose you to as much smoke as 100 or more cigarettes. The water does not filter out harmful chemicals, so hookah is not a safe alternative to cigarettes.
How much nicotine do you get from one hookah session?
A meta-analysis of four studies found that using a waterpipe was equivalent to smoking 2 to 10 cigarettes per day. Waterpipe smokers are exposed to sufficient doses of nicotine to lead to addiction, and hookah produces similarly increased blood nicotine levels and heart rate increases as cigarette use.
Can you get addicted to hookah?
Yes. Waterpipe smokers are exposed to sufficient doses of nicotine to lead to addiction. A meta-analysis of four studies found that hookah use was equivalent to smoking 2 to 10 cigarettes per day. The body's addictive response to hookah is comparable to what happens with cigarettes, so addiction is not limited to cigarette smoking.
What are the health risks of hookah smoking?
Waterpipe smoke is associated with an increased risk of cancer (including lung and other cancers), heart disease, lung disease, and adverse effects during pregnancy. It contains cancer-causing chemicals such as arsenic, cobalt, chromium, and lead, plus carbon monoxide. Sharing mouthpieces also increases the risk of communicable diseases transmitted through saliva.
Is secondhand hookah smoke dangerous?
Yes. Breathing in secondhand smoke from waterpipes is at least as harmful as exposure to secondhand cigarette smoke. One study found that during a typical one-hour hookah session, a waterpipe smoker likely generates ambient carcinogens and toxicants equivalent to that of 2 to 10 cigarette smokers, affecting everyone in the room.
How common is hookah use among teenagers?
Among high school seniors, 17% reported having smoked hookah in the past year, according to the Monitoring the Future survey. In one study, more than one in five high school students (20.9%) first learned about hookah simply by seeing a hookah bar in their community. Many hookah smokers also use cigarettes or other tobacco products.
What should I do if I smoke hookah or want to quit?
Do not assume hookah is a safe alternative to cigarettes. If you currently smoke hookah, you can become addicted. If you are trying to quit tobacco, discuss hookah with your healthcare provider. Nicotine replacement therapy and other cessation supports can help with nicotine addiction, regardless of the form of tobacco you use.
I smoke hookah and think it's safer than cigarettes — when should I get a second opinion about my health risks?
Hookah smoke contains cancer-causing chemicals including arsenic, cobalt, chromium and lead, and delivers nicotine equivalent to 2 to 10 cigarettes daily. A single 20-to-80-minute session can equal 100 or more cigarettes, and lung function damage matches cigarette smoking. If you have symptoms, a new diagnosis, or a treatment plan based on the belief that hookah is harmless, an independent review of your records, imaging and pathology can help confirm whether that assumption is affecting your care. Diagnostic Detectives Network provides independent expert second opinions.
Source Information
This patient-friendly article is based on the following peer-reviewed and public health source:
- Original title: "Not a safe alternative to cigarettes" (Waterpipes/Hookahs fact sheet)
- Publisher: American Cancer Society Cancer Action Network (ACS CAN)
- Publication date: March 2012
- Type: Evidence-based policy fact sheet reviewing peer-reviewed scientific literature
Key studies referenced in the original fact sheet include: Fielder, Carey, & Carey (2012) on hookah prevalence among college women; Sutfin et al. (2011) on waterpipe use in North Carolina college students; the American Lung Association (2007) estimate of 200–300 U.S. hookah bars; Smith et al. (2011) on high school students; Johnston et al. (2010) Monitoring the Future national survey data; Maziak et al. (2004) in Tobacco Control; Fromme et al. (2009) on indoor air contamination; Jacob et al. (2011) on nicotine and carbon monoxide exposure; Eissenberg & Shihadeh (2009) comparing toxicant exposure; Raad et al. (2011) meta-analysis on lung function; Neergaard et al. (2007) meta-analysis on nicotine exposure; Daher et al. (2010) on carcinogen emissions; and the World Health Organization (2005) Advisory Note on waterpipe tobacco smoking.
This patient-friendly article was created to translate the original scientific content into plain language for a general audience. All numerical data, statistics, and conclusions have been preserved from the original source. This content is provided for educational purposes and is not a substitute for professional medical advice.
