The Harmfulness of Hookah – how is it, really?
We are living in the modern age, where the main trend is a healthy lifestyle. This is really a good development and we can only be grateful for the society‘s progress.
Of course, many media and influencers are adapting to this trend, and on its wave they are fighting for anything that may seem unhealthy in the slightest. One of the current trends is the fight with hookahs. This is slowly becoming a modern witch hunt – in the true sense of the word. What do we mean?
The society condemns anything related to smoking and always finds their own arguments without being willing to discuss anything openly. To write somewhere that smoking hookahs is fundamentally different from smoking cigarettes is now practically an equivalent to social suicide.
The trend is clear – smoking is bad and it applies to all kinds smoking! And it’s really not surprising. In the case of cigarettes, the struggle with this industry has been going on for a really long time and it had to rely on a number of studies, and especially hard evidence, before it began to convince the next generation of society.
After a hard fight against all odds, the society succeeded in the impossible and the general perception turned against smokers. In the context of partial successes, it was only a matter of time before a practically fanatical society reached hookahs as another goal of their struggle. The fight against hookahs is just a culmination of the struggle with the smoking industry.
Society and media being blinded, one article after the other is now coming to attack the industry. After all, who would dare to go against the trend at the moment and try to really think about the whole topic from start to finish?
This attempt would really be close to the already mentioned social suicide…
So we’ve decided to commit social suicide and go, as some might believe, on a wild goose chase. We are convinced that smoking hookah is not as harmful as it is claimed to be.
Why do we think that? The current trend is to use context-sensitive citations, references to unrelated data, and, at best, pointing at the misuse of hookah and its effects in key studies and articles. These inaccuracies have triggered an unstoppable avalanche of articles condemning the use of hookahs.
1 Hookah Equals 100-500 Cigarettes?
It could be said that this whole hookah hunt began with a study by the US American University of Beirut, where basic measurements using standardized robot-smoking developed . Let’s simply break it down.
The approach to the measurement itself is a relatively good basis for the initial orientation. The problem with the hookah, however, is the different approach in its preparation, operation, use of individual products and, last but not least, in smoking itself.
In the case of a cigarette, the measurement is relatively stable and the simulated puffs (set for machine measurements on 35 ml of smoke once a minute for about 6 minutes) corresponds approximately to reality.
However, the setting of parameters for hookah smoking does not reflect the reality so much – 530ml smoke puff (approx. 3 s) every 17 s for 60 minutes. This may not be an exaggeration, but it is far from the normal behavior of smoking a hookah, and we will eventually explain why.
The frequency itself does not reflect reality much. Imagine sitting in a tea room, having hookah and discussing an interesting topic with someone. As part of smoking, you may pass on your hookah, sometimes you need to drink, bounce somewhere or engage in a discussion. In addition, you will usually have to change your coals several times during the whole ritual. And these are just some of the factors.
Another thing is the equipment itself. For a cigarette, it is relatively easy to perform an exemplary test. A cigarette is simply a cigarette and you only test individual brands. The simulation is quite simple.
However, with a hookah, the result is influenced by many other factors. From the tobacco used, the way it is packed, the bowl chosen, to the heat management (HMS, aluminum foil) or coal used.
For our discussed case, quick-light coals were used, these lay on the bowl with aluminum foil in direct contact with tobacco throughout the test.
The test result itself focuses mainly on the volume of smoke received and it is logically higher (according to the source study used, the titles use multiples such as 100 – 500x higher volume of inhaled smoke in a hookah than in a cigarette).
In principle, this statement is not (with regard to the input parameters, which we have already refuted) completely deceptive and can not be contradicted. The problem is that most media outlets take this issue out of context and automatically evaluate that a person smoking a hookah will logically absorb 100-500 times higher levels of pollutants.
But what about the smoke?
What Are We Actually Smoking?
A generally overlooked fundamental factor is the content of the smoke itself, especially the tar contained in it. The fact that cigarette smoke is harmful has been proven by many tests, and gradually the scientists have found about 4,700 chemicals that it contains .
A lesser known fact, however, is that only 142 of these chemicals have been identified in hookah smoke . Temperature is also crucial. For a cigarette, we move around 800-900 °C compared to a tobacco temperature of 100-200° C for a hookah.
The hookah heats the tobacco indirectly and thus only vaporizes the mixture. The smoke itself is largely made up of water and glycerin, which are biologically inactive.
From this basic comparison, it must be clear even to laymen that we are talking about significantly different issues here.
Nicotine – The Addictive Chemical
The often frequently mentioned claim of hookah opponents says that due to the higher volume of smoke, you also receive a higher dose of nicotine and thus take a high risk of addiction („smoke contains 6 times more nicotine“ State Health Institute ).
One of the studies focused on confirming this topic, which compared the intake of substances from 3 hookahs per day compared to 11 cigarettes (13 people participated in both smoking methods for comparison). Despite not using modern equipment and the procedure for preparing the hookah (classic aluminum foil, quick-light coals), the measured values are surprising.
Even when smoking 3 hookahs in a row, the total nicotine intake was significantly lower than that of 11 cigarettes . The development of nicotine dependence in connection with hookahs has not yet been proven in any of the studies that focused on this topic .
The CO Killer
Another bogey discussed is the concentration of carbon monoxide (CO) when smoking a hookah. This statement is substantiated by many measurements and is essentially true [1, 3].
However, it is necessary to realize how the whole process takes place and where this gas is created. The problem is the coal itself. During its combustion, most of the CO and also all other measured harmful substances are generated (up to 90% ). The measured values and the style of intake of this gas can then be very well compared to grilling on classic charcoal , from which we can also base the recommendations for the prevention of the effects of this gas on health:
- Always use high quality (pure) natural coal.
- Coal must always be well lit from all sides
- The whole room (especially the space for starting the coal itself) must be well ventilated.
With regard to coal, as the cause of 90% of pollutants in total, it is desirable to separate it from the tobacco as much as possible. The biggest benefit in this matter seems to be Kaloud Lotus – the so-called Heat Management System and its imitations, which further separate the coals from the tobacco itself and thus help to significantly reduce the transfer of coal particles into the tobacco.
However, despite the significant help this system offers, Kaloud Lotus does not completely prevent the transfer of components that evaporate from the coal and which are then passing through tobacco.
What Is The Actual Impact On Health Then?
A real influence of long-term regular hookah smoking was attempted in a study published in 2008 . This focused on the presence of Carcino Embryonic Antigen (CEA) in the smoker’s body. This substance is considered to be one of the indicators of cancer risk and its presence affects, for example, smoking.
The study was performed on 59 hookah smokers aged 20-80 years, who regularly smoked a hookah from 8 to 65 years. 36 non-smokers were also present to compare the final differences.
These 59 people were divided into 3 groups according to the frequency of hookah smoking:
The overall average of CEA in hookah smokers was virtually indistinguishable from that of non-smokers, and was thus many times different from the CEA measured in smokers (3.58 ng / ml vs. 9.19 ng / ml). However, it is necessary to mention that the group of the strongest hookah smokers has reached an average of increased values (5.11 ng / ml).
Importantly, given the age of the smokers and the location of the study (for smokers from Pakistan), one hookah there contains as much as 60-120 g (1-2 „chattak“) of tobacco and is smoked on obsolete equipment (chilam bowl) with falling ashes from the coals. Most older smokers also smoked tobacco without molasses, which evaporates differently – such as Tombak.
With this in mind, the conclusions are very surprising and may serve to give an idea of the possible effects of modern hookah smoking, which is very different (typically about 15-20 grams of modern purified tobacco and natural tested charcoal in a modern heat management system for heat regulation).
Statement of the National Institute of Public Health  (note: Czech health institute):
An average of 70 liters of smoke is generated during one hookah session. With an average hour of sitting by a hookah, a smoker inhales approximately 100-200 times more smoke than when smoking a single cigarette.
- With regard to the parameters used to measure the volume of smoke, this statement is true, but it is based on an unrealistic scenario (see, chapter „1 pipe as 100 (up to 500) cigarettes“)
In connection with the method used to heat tobacco and the size of the ‚burning‘ coals, 30-100x more tar is produced, 17-50 times more carbon monoxide and the smoke contains 6 times more nicotine.
- The statement is taken out of context and does not take into account the content of the volume of harmful substances ingested, which is almost 40 times higher for cigarettes. Also surprising is the very low intake of nicotine, many times lower than for cigarettes.
Water in the vase of a hookah mainly cools the smoke. Even after passing through water, the smoke contains high doses of toxic components including carbon monoxide, heavy metals and a number of cancer-causing substances.
- Water filters the individual components with an efficiency from 4.2 to 78.6% with an overall average efficiency of 38% . Surprising is the significant reduction of nicotine and its low presence in the measurement . Only 142 harmful components were identified in hookah smoke, compared to more than 4700 for cigarettes .
Commonly used sources of heat (coals) that are heating the tobacco, probably lead to an increase in health risks, because their burning releases toxic substances into the smoke, incl. heavy metals and CO.
- TRUE. One of the few true statements. According to relevant studies, up to 90% of the measured pollutants come from the combustion of carbon. The result is comparable to charcoal grilling.
Sharing a mouthpiece when smoking a hookah poses a risk of transmitting infectious diseases including tuberculosis and infectious hepatitis.
- TRUE. But it’s very similar to sharing anything. To prevent direct transmission, we recommend disposable mouthpieces and ideally one hookah per smoker at the table.
Passive smoking of a mixture of tobacco smoke and carbon smoke from hookahs is also risky for non-smokers.
- Hookah smoke contains significant amounts of harmless glycerin and water. The content of harmful components is many times lower than that of cigarette smoke. Ventilation and proper airflow is then suitable to reduce the risk of CO poisoning.
Regular hookah smoking can lead to nicotine addiction.
- The nicotine content of hookah smoke is significantly lower than that of cigarettes, and none of the many studies had shown for hookah to cause addiction.
No study has shown that the passage of smoke through water would reduce the amount of toxic substances and thus the danger of such smoking. On the contrary, the passage of an aerosol through water cools this mixture and the smoker is thus able to inhale the smoke more and deeper into the lungs, which may increase the absorption of hazardous substances into the body.(Hrubá, 2015) (note: Czech health/smoking expert)
- NOT TRUE. Water filters the individual components with an efficiency from 4.2 to 78.6% with an overall average efficiency of 38% . Surprising is the significant reduction of nicotine and its low presence in the measurement .
- Public health intervention for narghile (hookah,shisha) use requires a radical critique of the related „standardised“ smoking machine – Chaouachi, K. (2009)
- Hookah smoking and cancer: carcinoembryonic antigen (CEA) levels in exclusive/ever hookah smokers – Harm Reduct J. (2008)
- Comparison of nicotine and carcinogen exposure with water pipe and cigarette smoking – Peyton J. (2013)
- Hookah warning poster. – National Institute of Public Health (2007)