Smoking hookah: Health risks and side effects

You probably know that smoking cigarettes poses many health risks like cancer, heart disease and lung disease — in addition to being addictive and hard to quit. But another type of tobacco is becoming more popular in the United States: hookah.

Hookahs, also known as shisha, are water pipes with a flexible hose, bowl and mouthpiece used to smoke flavored tobacco mixtures that may contain dried fruit, molasses, honey or other flavorings. The practice started in the 16^th century in India before spreading to North Africa and the Middle East.

These days, it’s a social activity with dedicated lounges where people can sit, talk and smoke. This contributes to its popularity.

But hookah poses many of the same dangers as cigarettes, says Maher Karam-Hage, M.D., medical director of UT MD Anderson’s Tobacco Research and Treatment Program. Depending on how much smoke you inhale, it may be even more harmful to your health.

“Lung cancer is one of the biggest concerns, but smoking also affects many other organs,” he explains.

Read on to learn more about the dangers of hookah.

What is hookah smoking?

When you smoke hookah, you inhale its toxic gases after it passes through water. For a long time, Karam-Hage says, it was thought that water purified the smoke and removed its toxins. But that’s not true. All the harmful chemicals found in tobacco are present in hookah smoke, too. Hookah also contains nicotine, which can lead to nicotine dependence.

“The water mainly cools the smoke, which may make it easier to inhale more deeply,” he says. “Hookah smoke can also contain a lot of carbon monoxide. That comes not only from the incomplete burning but also from the charcoal traditionally used to heat it.”

Incomplete burning is how tobacco is used. It burns without having enough oxygen to completely burn up, producing many harmful chemicals instead.

Several studies suggest that carbon monoxide exposure from hookah smoking is many times higher than from cigarette smoking.

Is hookah bad for you?

Hookah smoking is one of the most harmful ways to use tobacco or nicotine. It carries many of the same health risks as smoking cigarettes.

Toxin exposure

In terms of carbon monoxide, inhaling hookah smoke can be similar to breathing car exhaust fumes. People continue to breathe normal air between puffs, which helps reduce the immediate effects of carbon monoxide exposure, Karam-Hage explains.

Carbon monoxide is just one of thousands of toxic chemicals created when tobacco is burned. Many of the same harmful chemicals are also found in cigarette smoke.

“Tobacco smoke has at least 7,000 known chemicals,” Karam-Hage says. “About 70 of those are known carcinogens, which means they can cause cancer.”

Cancer, cardiovascular disease and chronic lung disease account for the vast majority of serious illnesses and deaths caused by smoking. Hookah is associated with these same health risks.

Hookah can cause cancer

Hookah tobacco and smoke contain cancer-causing chemicals linked to numerous types of cancer, including:

• Lung cancer
• Bladder cancer
• Oral cancer (including mouth and throat cancer)
• Stomach cancer
• Cervical cancer

Other health risks from smoking hookah

In addition to cancer, smoking hookah can also increase the risk of heart and blood vessel problems, including high blood pressure (hypertension), heart attacks and strokes.

Then there’s chronic lung disease, which includes conditions like chronic obstructive pulmonary disease (COPD).

“The lungs are designed to breathe air, not smoke. Repeated smoke exposure damages them over time,” Karam-Hage says.

Other possible health problems caused by long-term hookah use include pregnancy complications, harm to an unborn baby and gum disease.

“The major health risks are similar to those from other forms of smoking,” he says.

Hookah contains nicotine

Nicotine is the addictive stimulant found in tobacco. It triggers the release of chemicals in your brain that create pleasurable feelings and contributes to tobacco addiction. It’s also synthetically present in products marketed as tobacco-free.

Most hookahs contain nicotine. But unlike cigarettes, the amount of nicotine in hookah varies greatly based on how the product is handled when it’s made, as well as how much or how deeply it’s inhaled and how long the hookah session lasts.

“Because nicotine levels vary so much, there isn't one amount that applies to every hookah product,” Karam-Hage says. “Hookah tobacco can contain a lot of nicotine, but the amount a person absorbs depends heavily on how they use it.”

While nicotine is addictive, it does not cause cancer, COPD, heart attacks or stroke. Yet it’s not totally harmless.

Hookah creates secondhand smoke

Because hookah produces smoke, you can be exposed to secondhand smoke nearby, just as you can with cigarettes or cigars.

Hookah smoking and addiction

If you smoke hookah regularly, you are more likely to become dependent on nicotine. While patterns of hookah use vary around the world, any regular nicotine exposure can lead to dependence.

What about tobacco-free hookah or e-hookah?

There are tobacco-free hookah alternatives, and some of these products contain nicotine. These products are often made from sugarcane, tea leaves or other plant materials. However, they still produce many of the same toxic and cancer-causing chemicals such as carbon monoxide, because burning is part of the hookah smoking process.

“Inhaling smoke is harmful even if tobacco and nicotine have been removed,” Karam-Hage says. “If you burn and inhale another plant material instead of tobacco, you are still breathing smoke and toxic chemicals.”

There's also e-hookah, which removes burning and instead heats liquids — just like e-cigarettes. But Karam-Hage says that these are not harmless as there are still plenty of hazardous chemicals present in the liquids.

“They are not harmless when inhaled,” he says.

How the FDA regulates hookah products

Since 2016, the Food and Drug Administration (FDA) has regulated hookah tobacco under rules that deemed hookah as a tobacco product subject to the 2009 Family Smoking Prevention and Tobacco Control Act. This allows the agency to set sales age limits, require health warnings to be printed on packaging and mandate ingredient reporting.

The FDA does not approve or consider any tobacco products safe. That includes hookah.

Why do some people think hookah is safe?

“People may believe that passing the smoke through water removes the toxins. But it does not,” Karam-Hage says.

Another reason may be that hookah is often viewed as a social activity. But the health dangers remain.

Is hookah smoking safer than smoking cigarettes?

No. Both cigarettes and hookah are harmful. Hookah should not be considered a safe alternative to smoking cigarettes.

That being said, it’s difficult to compare the toxicity of the two because they’re consumed differently.

“Hookah sessions vary so much in length and intensity,” Karam-Hage says. “One person may take only a few puffs. Another person may smoke hookah for hours. Because the exposure varies so much, it is difficult to reliably say that one hookah session equals a specific number of cigarettes. Using both cigarettes and hookah can also be especially harmful because your lungs are exposed to different types of irritants.”

Which is better: hookah or vaping?

Vaping generally exposes you to fewer toxic chemicals than smoking hookah or cigarettes because there is no burning. Some people use vaping as a step away from combustible tobacco products, but it should not be your first quit strategy unless you are not able to quit with the help of medications and counseling. It may create additional risks if you both vape and smoke hookah.

“Vaping is not harmless,” Karam-Hage says. “Ideally, people should stop using tobacco and nicotine products entirely. But if someone cannot quit, moving away from combustible, or burnable, tobacco can reduce some of the harm.”

If you’re a UT MD Anderson patient, you can get help quitting smoking through our Tobacco Research and Treatment Program. Ask your care team for a referral. If you live in Texas but are not a UT MD Anderson patient and you want to participate in a clinical trial to quit smoking cigarettes, you can participate by registering at NicotineStudy.org.

You also can get phone and text support through the National Institutes of Health Quitline by calling 1-800-784-8669, texting QUIT to 47848, or visiting SmokeFree.gov. If you live in Texas, you can use the Texas Tobacco Quitline by calling 1-877-YES-QUIT or visiting YESQUIT.org.

Are there any safe hookahs?

Karam-Hage says he wouldn’t call any hookah product safe, whether it removes tobacco or nicotine. While some products are less harmful than others, they all pose health risks.

Learn more about tobacco cessation studies at UT MD Anderson.