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Hookahs, or waterpipes, are the first new tobacco trend in the 21st century, giving new popularity to an old form of tobacco use. Hookah use is becoming very popular with 18 to 24 year olds and college students, who believe it to be safe. However, misperceptions about the safety of hookahs are widespread and need to be addressed.

Background/ History of Hookah Use

picture of a waterpipe (hookah)

The hookah is used to smoke specially made tobacco through a waterpipe. The tobacco is indirectly heated with burning embers or charcoal which filters the smoke through a bowl of water. The smoke is then drawn through a rubber hose to a mouthpiece, where it is inhaled by the user.

Hookahs are also called narghile or narghila, and shisha or sheesha.

Hookahs generally consist of four main parts:

  1. The bowl where the tobacco is heated;
  2. The base filled with water or other liquids;
  3. The pipe, which connects the bowl to the base; and
  4. The hose and mouthpiece through which smoke is drawn.

Hookah smoking began in ancient Persia and India and spread throughout the Middle East and Asia during the 15th century. In the late 20th century, new flavored items were added to the mixture to make the hookah more appealing to women. As people moved to Europe and the United States from the Middle East and Africa, hookah cafes began appearing in European cities and are now growing in popularity in the United States.

Hookahs have become popular among the urban youth, young professionals and college students.

Additionally, new forms of electronic hookah smoking, or e-hookah, have been introduced. These products are battery powered and turn liquid containing nicotine, flavorings, and other chemicals into an aerosol, which is inhaled, much like e-cigarettes.

Health Effects of Hookah Smoking

The research on hookah use shows that smoking through a hookah carries the same or similar health risks as cigarette smoking. These negative health effects include increased risk of heart disease, lung, oral, and bladder cancer.

While studies of smoke from hookahs found that it has similar amounts of nicotine, tar and heavy metals as other tobacco products, some experts think that hookah smoking actually increases exposure to dangerous substances over other products. This is because of the way hookah smoking differs from cigarette smoking.

Hookah smokers smoke over a much longer period of time, often 40 to 45 minutes, rather than the 5 or 10 minutes it takes to smoke a cigarette. Because the inhalation and exposure to smoke happens over a longer and more sustained amount of time, a hookah smoker could possibly breathe in as much smoke in a single session as smoking 100 or more cigarettes.

Another problem with hookah smoking is that wood cinders or charcoal are usually used to burn the tobacco. These substances, when burned, release high levels of dangerous chemicals, including carbon monoxide and metals. Some research shows that hookah smoke is actually more dangerous than cigarette smoke, because it includes smoke from the tobacco itself and smoke from the heat source used to burn the tobacco.

Although more research needs to be done to test whether there are long-term health effects of hookah smoking, existing studies show that it carries many of the same risks as cigarette smoking and should not be used as a safe alternative to smoking.

Additionally, secondhand smoke from hookahs can be a health risk for nonsmokers. It contains smoke from the tobacco as well as smoke from the heat source (e.g. charcoal) used in the hookah.

Perception and Awareness

Hookahs are thought to be more enjoyable for smokers, because the smell, taste and smoothness of the sweetened tobacco provide a much less irritating smoking experience than cigarette smoking.

Experienced smokers sometimes add other liquids, such as fruit juice or wine, to change the taste of the smoke. Hookah smoking is also usually less expensive than cigarette smoking, which gives people another reason to want to use hookah.

Current Estimate of Hookah Use in the U.S.

Hookah use by youth and college students is increasing. In 2010, the Monitoring the Future survey found that among high school seniors in the United States, about 1 in 5 boys (17 percent) and 1 in 6 girls (15 percent) had used a hookah in the past year.

A 2010 study at the University of Nevada, Las Vegas (UNLV) found that 15.2 percent of college students there had tried hookah smoking in the last 30 days.

Hookah Bars and Cafes

The rise in hookah smoking in the United States may be the result of marketing for hookah cafes done in and around colleges and universities, targeting 18 to 24 year olds. Hookah bars and cafes have sprung up in cities and towns near large colleges or universities, like UNLV, despite states with strong smoke-free air laws.

Based on U.S. business listings, more than two-thirds of the states currently have hookah bars or cafes.

State Regulations, Legislation, and Policies

Although many states now have laws banning smoking in almost all public places and workplaces, hookah bars and cafes have been exempted from these laws in many states in a number of different ways.

Hookah bars sometimes qualify for exemptions either as “retail tobacco establishments” or “tobacco bars or cigar lounges” or businesses that sell only tobacco products, whether for use onsite or elsewhere.

Smoke free air laws, in many cases, have seemed to have a positive effect on hookah bars, actually making them more popular as one of the few indoor places where smoking is still allowed.


American Lung Association, Tobacco Policy Trend Alert. "An Emerging Deadly Trend: Waterpipe Tobacco Use," February 2007.

American Lung Association, Smokefree Communities Project. “Hookah Smoking: A Growing Threat to Public Health Issue Brief,” 2011.

Centers for Disease Control and Prevention. “Smoking and Tobacco Use: Hookahs,” 2013.



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