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Harvard Commentaries
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Reviewed by the Faculty of Harvard Medical School

Minding Your Mind Minding Your Mind

The Hazards of Hookah

November 16, 2013

By Michael Craig Miller M.D.

Harvard Medical School

Waterpipes, for people of a certain age, are remembered as fixtures of the 1960s and 1970s. They're back — and not just for smoking marijuana. They are increasingly popular for smoking tobacco.

The Allure of Hookah

Part of hookah's appeal is aesthetic. The names for it are romantic, exotic, or whimsical: hookah, shisha, boory, goza, nargile, arghile, hubble bubble. The pipes are designed to stand upright on a table, while smokers recline in comfortable chairs or couches. The devices themselves, made of glass or metal, can be beautiful to look at. The pipes serve up smoke to several people at once, so it is a social activity, too.

Waterpipe smoking is widely perceived to be less harmful and addictive than smoking cigarettes or other forms of tobacco. This may be partly true. But public health officials worry that this perception may be falsely reassuring. Risks are certainly elevated relative to people who never expose themselves to tobacco smoke. And, in large part because of the way people smoke while using a waterpipe, many public health officials believe this form of smoking may be just as addictive and perhaps even more harmful than cigarette smoking.

Smoking hookah is more of an undertaking than lighting up a cigarette, but that doesn't mean that users are getting less smoke. And the water in the pipe provides no protective effect. In fact, since the water cools the smoke, users can take in much more of it, along with larger quantities of toxins.

Thus, hookah smoking has significant long-term health effects and it can promote tobacco addiction as well.

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Hookah Use Is On the Rise

Experts estimate that 100 million people worldwide smoke tobacco from waterpipes daily. Young people rarely used waterpipes in the 1990. But times have changed. The Global Youth Tobacco Survey collected data on more than 90,000 adolescents ages 13 to 15 living in 20 countries in the Eastern Mediterranean region (where hookah smoking is part of the culture). It found that 3% of girls and 7% of boys smoked cigarettes, while 10% of girls and 16% of boys used tobacco by other means, mainly the waterpipe.

Preliminary studies in the United States show that both high school and college students use waterpipes.

  • One study in a Midwestern suburb found that 27% of high school students ages 14 to 18 had tried waterpipe smoking at least once. A survey of high school students in a southern California community yielded similar results, with about 26% having tried it and a little more than one in 10 as current users.1
  • An Internet survey at Johns Hopkins University found that 15% of freshmen had tried waterpipe smoking at least once in the previous month.
  • A survey of undergraduates at Virginia Commonwealth University found that 48% of those who responded had tried waterpipe smoking at least once. Twenty percent were active users at the time of the survey.
  • A California survey showed that hookah use had increased 40% between 2005 and 2008.2

Due to the increase in waterpipe smoking, the World Health Organization (WHO) issued a public advisory in 2005 about the possible health hazards. Since then, more research has come out that makes the risks clear.

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The Unique Hazards of Hookah

The amount of smoke inhaled

Researchers at the American University of Beirut reported that smokers in a hookah café inhaled more often and for longer periods than typical cigarette smokers. Some smokers inhaled 10 times as often as the typical cigarette smoker, and each inhalation contained as much as 10 times the amount of smoke obtained from an entire cigarette.

The WHO scientists estimated that by puffing longer and inhaling puffs of greater volume, a waterpipe smoker could inhale the equivalent of 100 cigarettes (five packs) or more during a single waterpipe session!

They figured that cigarette smokers usually take 8 to 12 puffs from each cigarette, with each puff delivering 40 to 75 milliliters (ml) of smoke, over a period of five to seven minutes. In all, typical cigarette smokers therefore inhale about 0.5 to 0.6 liters of smoke from a single cigarette (or 10 to 12 liters of smoke per pack). By contrast, a waterpipe smoker may inhale as much as a liter of smoke with each puff. And because waterpipe sessions can go on for a half-hour or more, smokers take as many as 50 to 200 puffs per session.

Exposure to toxins

Some hookah smokers argue that they don't inhale. Instead, they puff as if on a pipe — and believe this reduces the health hazards. However, researchers who have measured absorption of nicotine and other substances in hookah smoke say otherwise. Their conclusion is that hookah smokers may be exposed to lower concentrations of toxins than cigarette smokers, but they're still getting much more exposure than nonsmokers.

The studies indicate that hookah smokers are absorbing high levels of toxins and carcinogens that may contribute to the development of heart disease, lung cancer and respiratory diseases. And although some nicotine is filtered from smoke as it passes through the water in the pipe, WHO scientists concluded that waterpipe smokers are still exposed to enough nicotine to become addicted.

Many states exempt "hookah lounges" from the usual laws dictating that public spaces be smoke-free. Three-quarters of America cities ban smoking in bars, but 90% of them allow such exemptions.3 A survey of 10 hookah lounges showed the air quality to range from “unhealthy” to "hazardous."4

For instance, a study published in 2007 inNicotine and Tobacco Research analyzed four studies that measured levels of cotinine — a chemical used to assess nicotine exposure — in the urine of waterpipe smokers. Although the authors cautioned that the amount of nicotine produced can vary depending on the design of the waterpipe, type of tobacco used, burn temperature and duration of use, the findings nevertheless are troubling. The researchers found that using a waterpipe every day produced cotinine levels that indicated a nicotine absorption rate equivalent to smoking 10 cigarettes a day. In people who did not use a waterpipe every day, a single session of hookah smoking produced cotinine levels equivalent to those in people who smoked two cigarettes a day.

Becoming addicted

Little research is available on the long-term health hazards of hookah smoking, including the possibility of addiction. But the studies that have been published report problems similar to those caused by other types of tobacco smoking.

Unfortunately, few studies have been conducted on how to help people stop waterpipe smoking. Common treatments for nicotine addiction may be worth trying where there is such an addiction. But smoke-ending therapies tested in cigarette smokers may not help hookah smokers to quit, because the triggers — such as the look of the pipe, the smell of the smoke and the social aspect — may contribute in a unique way to cravings and addiction.

Pregnancy risks

Pregnant women who use waterpipes are more likely than other women to give birth to babies with low birth weights, low Apgar scores and respiratory distress syndrome. Other studies have shown that hookah smoking increases the chances of gum disease. Two teams have concluded that waterpipe use contributes to cardiovascular problems. One group of researchers, for example, found it increased heart rate and blood pressure.

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The Bottom Line

Until more is known about the relative dangers of hookah and how best to help hookah smokers quit, public health officials advise both clinicians and smokers to become aware of the potential dangers. While hookah is alluring, it also appears to be a health hazard. Clearly, there are safer ways to relax.

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Michael Craig Miller, M.D. is Editor in Chief of the Harvard Mental Health Letter. He is also associate physician at Beth Israel Deaconess Medical Center and assistant professor at Harvard Medical School. He has been practicing psychiatry for more than 25 years and teaches in the Harvard Longwood Psychiatry Residency Program.

1Smith, J. R., T. E. Novotny, et al. (2011). "Determinants of Hookah Use among High School Students." Nicotine & tobacco research : official journal of the Society for Research on Nicotine and Tobacco. 2Smith JR, Edland SD, Novotny TE, et al. Increasing hookah use in California. American journal of public health. Oct 2011;101(10):1876-1879. 3Primack BA, Hopkins M, Hallett C, et al. US health policy related to hookah tobacco smoking. American journal of public health. Sep 2012;102(9):e47-51. 4Fiala SC, Morris DS, Pawlak RL. Measuring indoor air quality of hookah lounges. American journal of public health. Nov 2012;102(11):2043-2045.

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