The Hookah Lounge

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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.