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Table of Contents
Year : 2020  |  Volume : 3  |  Issue : 1  |  Page : 1-2

Hookah and cigarette smoking: Two sides of the same coin

Department of Medicine, The University Sleep Disorders Center, College of Medicine, King Saud University, Riyadh, Saudi Arabia; The Strategic Technologies Program of the National Plan for Sciences and Technology and Innovation in the Kingdom of, Saudi Arabia

Date of Submission15-Dec-2019
Date of Acceptance19-Dec-2019
Date of Web Publication06-Jan-2020

Correspondence Address:
Ahmed Salem BaHammam
The University Sleep Disorders Center, College of Medicine, King Saud University, Box 225503, Riyadh 11324
Saudi Arabia
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/JNSM.JNSM_71_19

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How to cite this article:
BaHammam AS. Hookah and cigarette smoking: Two sides of the same coin. J Nat Sci Med 2020;3:1-2

How to cite this URL:
BaHammam AS. Hookah and cigarette smoking: Two sides of the same coin. J Nat Sci Med [serial online] 2020 [cited 2023 Jan 28];3:1-2. Available from: https://www.jnsmonline.org/text.asp?2020/3/1/1/275173

“Hookah,” which is also known as “Narghileh,” “Maassel,” or “Shisha,” is a form of waterpipe smoking. Hookah is composed of a tobacco bowl known as the head where tobacco (that is processed and flavored) is placed, a body, a water bowl, a hose, and a mouthpiece.[1] Charcoal is positioned on the top of the head that contains tobacco. When the smoker inhales through the hose, the air is drawn into and around the charcoal. The generated heated air passes through heated tobacco to produce the mainstream smoke aerosol. This smoke aerosol passes through the water bowl producing bubbles and goes through the hose to the smoker. The average hookah smoking session consists of 171 inhalations (each approximately 0.5 L) of 2.6 s duration at a frequency of 2.8 inhalations/min.[2]

It has been reported that waterpipe smoking was invented in India by a physician during the time of Emperor Akbar (1556–1605 CE).[3] The physician thought that passing the smoke through water will make it less harmful or even harmless.[3] This myth was carried over by many waterpipe users today who think that the practice of hookah smoking is relatively safe compared to cigarette smoking.[4] An analysis of YouTube videos related to cigarette and waterpipe smoking revealed that user-generated videos of waterpipe smoking were less likely to acknowledge the adverse health effects of smoking compared to cigarette smoking videos.[5] The misconception that drawing tobacco smoke through water makes hookah smoking less harmful than cigarette smoking is widespread and adds to its rising popularity and acceptability.[4] A recent study quantitatively assessed the effects of the water filtration stage of the hookah smoking process on the inhaled levels of several toxic metals and reported that the percentage of metals removed during the water bubbling stage was approximately 3% of the total metals.[6] This small reduction is unlikely to protect the smoker against exposure to the majority of potentially toxic metals.[6] In Saudi Arabia, there has been an alarming increase in hookah smoking among youths despite the current strict regulation on tobacco sales for youths.[7],[8]

In this issue of the JNSM, Albacker et al., in a retrospective study, compared the outcomes of hookah versus cigarette smoking in 246 patients presenting with acute myocardial infarction.[9] The authors divided smokers into two groups (hookah smokers and cigarette smokers) and assessed the following outcomes: in-hospital mortality, the number of diseased vessels, type of intervention, and recurrence of ischemia in both the groups.[9] The median number of cigarettes or cigarette equivalent (in hookah smokers) per day was similar in the two groups. The study revealed that both groups had similar outcomes in the number of diseased vessels, type of intervention, recurrence of symptoms, and mortality.[9] The current study adds to the available literature, indicating that hookah smoking is not less harmful than conventional cigarette smoking.[10],[11]

Several studies have reported the presence of significant amounts of carbon monoxide (CO), aldehydes, polycyclic aromatic hydrocarbons (PAHs), ultrafine particles, and respirable particulate matter in second-hand hookah smoke.[12],[13] Moreover, hookah smoking may have a higher risk for second-hand smoking than cigarette smoking as CO, PAHs, and volatile aldehydes are greater in hookah smoke than cigarette smoke.[14],[15] Furthermore, the direct emissions of toxicants from hookah when smoking tobacco-free preparations were comparable to those from hookah smoked with tobacco-based preparations. Therefore, smoke from a tobacco-free hookah has the same toxicant contents and biological hazards as the conventional tobacco-based products.[16] Thus, as the title of this editorial states, cigarette smoking and hookah smoking are two sides of the same coin. Such data should be publicized to help correct the misconception among most hookah smokers that waterpipe smoking is safer, given the lower frequency of smoking sessions and the presence of the water filter that presumably filters all toxins.

Another misleading concept that is promoted by the manufacturers of hookah is the availability of some accessories that are claimed to reduce the harmful effects of the smoke, such as mouthpieces containing activated charcoal or cotton, chemical additives to the water bowl, and plastic mesh fittings to create smaller bubbles. However, none of the promoted accessories has been shown to be effective in reducing smokers' exposure to toxins or in diminishing the risks for tobacco-related complications.[1]

Strict regulations to combat the accelerating trend of hookah use among the general public, particularly minors, are urgently needed. The Saudi Ministry of Rural and Municipal Affairs has imposed new regulations on restaurants and cafés serving hookah.[17] The new regulations aim to reduce hookah use inside the cities and to increase fee on cafés and restaurants serving hookah.[17]

In addition, the World Health Organization and the American Lung Association published recommendations that include the following:[1],[18]

  • The Food and Drug Administration should maintain authority over the manufacturing and marketing of tobacco used in hookah and implement strict rules to these products as needed to protect public health
  • Forbid any misleading health claims on waterpipe tobacco packaging and all waterpipe accessories
  • Mandate health warning labels on waterpipe tobacco (similar to warnings on conventional cigarette packages)
  • Regulations are needed to remove flavorings in hookah tobacco as flavorings have been shown to increase use in youth and young adults
  • Apply and enforce laws that prohibit the sale of hookah tobacco to minors
  • Prohibiting advertising, even in the electronic media and websites, can help discourage youngsters from trying hookah smoking
  • Starting public awareness campaigns that increase awareness about the deleterious health effects of hookahs and refute the misconceptions about reduced harm.


This work was supported by the Strategic Technologies Program of the National Plan for Sciences and Technology and Innovation in the Kingdom of Saudi Arabia (MED511-02-08).

  References Top

World Health Organization. Study Group on Tobacco Product Regulation (TobReg). Waterpipe tobacco smoking: Health effects, research needs and recommended actions for regulators. Geneva, Switzerland: World Health Organization; 2015.  Back to cited text no. 1
Shihadeh A, Azar S, Antonios C, Haddad A. Towards a topographical model of narghile water-pipe café smoking: A pilot study in a high socioeconomic status neighborhood of Beirut, Lebanon. Pharmacol Biochem Behav 2004;79:75-82.  Back to cited text no. 2
Chattopadhyay A. Emperor Akbar as a healer and his eminent physicians. Bull Indian Inst Hist Med Hyderabad 2000;30:151-7.  Back to cited text no. 3
Maziak W, Eissenberg T, Ward KD. Patterns of waterpipe use and dependence: Implications for intervention development. Pharmacol Biochem Behav 2005;80:173-9.  Back to cited text no. 4
Carroll MV, Shensa A, Primack BA. A comparison of cigarette- and hookah-related videos on YouTube. Tob Control 2013;22:319-23.  Back to cited text no. 5
Al-Kazwini AT, Said AJ, Sdepanian S. Compartmental analysis of metals in waterpipe smoking technique. BMC Public Health 2015;15:153.  Back to cited text no. 6
Akl EA, Gunukula SK, Aleem S, Obeid R, Jaoude PA, Honeine R, et al. The prevalence of waterpipe tobacco smoking among the general and specific populations: A systematic review. BMC Public Health 2011;11:244.  Back to cited text no. 7
Daradka H, Khabour O, Alzoubi K, Nakkash R, Eissenberg T. Tobacco and waterpipe use among university students in Saudi Arabia: Impact of tobacco sales ban. East Mediterr Health J 2019;25:111-8.  Back to cited text no. 8
Albacker TB, Barghouthi RA, Al Saadan Y, Tokhta M, Alkorbi A, Abou Almakarem S, et al. Does hookah smoking carry less cardiovascular risks than cigarette smoking in patients presenting with myocardial infarction? J Nat Sci Med 2020;3:48-52. [doi: 10.4103/JNSM.JNSM_26_19].  Back to cited text no. 9
Husain H, Al-Fadhli F, Al-Olaimi F, Al-Duraie A, Qureshi A, Al-Kandari W, et al. Is smoking shisha safer than cigarettes: Comparison of health effects of shisha and cigarette smoking among young adults in Kuwait. Med Princ Pract 2016;25:117-22.  Back to cited text no. 10
Kadhum M, Sweidan A, Jaffery AE, Al-Saadi A, Madden B. A review of the health effects of smoking shisha. Clin Med (Lond) 2015;15:263-6.  Back to cited text no. 11
Kumar SR, Davies S, Weitzman M, Sherman S. A review of air quality, biological indicators and health effects of second-hand waterpipe smoke exposure. Tob Control 2015;24 Suppl 1:i54-i59.  Back to cited text no. 12
Markowicz P, Löndahl J, Wierzbicka A, Suleiman R, Shihadeh A, Larsson L. A study on particles and some microbial markers in waterpipe tobacco smoke. Sci Total Environ 2014;499:107-13.  Back to cited text no. 13
Daher N, Saleh R, Jaroudi E, Sheheitli H, Badr T, Sepetdjian E, et al. Comparison of carcinogen, carbon monoxide, and ultrafine particle emissions from narghile waterpipe and cigarette smoking: Sidestream smoke measurements and assessment of second-hand smoke emission factors. Atmos Environ (1994) 2010;44:8-14.  Back to cited text no. 14
Shihadeh A, Schubert J, Klaiany J, El Sabban M, Luch A, Saliba NA. Toxicant content, physical properties and biological activity of waterpipe tobacco smoke and its tobacco-free alternatives. Tob Control 2015;24 Suppl 1:i22-i30.  Back to cited text no. 15
Hammal F, Chappell A, Wild TC, Kindzierski W, Shihadeh A, Vanderhoek A, et al. 'Herbal' but potentially hazardous: An analysis of the constituents and smoke emissions of tobacco-free waterpipe products and the air quality in the cafés where they are served. Tob Control 2015;24:290-7.  Back to cited text no. 16
Jafar M. New Saudi Rules on Hookah Leave Businesses, Consumers Confused. Arab News; 2019. Available from: https://www.arabnews.com/node/1569011/saudi-arabia. [Last accessed on 2019 Dec 15].  Back to cited text no. 17
American Lung Association. Hookah Smoking A Growing Threat to Public Health. Smokefree Communities Project; 2011. p. 1-7. Available from: https://www.lung.org/assets/documents/tobacco/hookah-policy-brief-updated.pdf. [Last accessed on 2019 Dec 15].  Back to cited text no. 18

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