Hi Alice,

I smoke hookah on occasion, but am not a regular hookah smoker. Recently some of my friends have expressed interest in smoking hookah but are concerned about the health side effects; needless to say, for very legitimate reasons. However, non-tobacco shisha, made simply of herbs and molasses, claims to be a healthier alternative to regular shisha that contains tobacco. Though I can assume it is not without its shortcomings, is it still healthier then regular tobacco products, as it claims?

Dear Reader,

You’re correct that smoking hookah doesn't have to mean ingesting tobacco or nicotine, which are common substances associated with smoking. However, all types of hookah prompt exposure to harmful substances, primarily because they all involve burning charcoal and inhaling smoke that contain toxins such as carbon monoxide and polyaromatic hydrocarbons. This means that, even without nicotine present, tobacco-free hookah may lead to health risks similar to that of traditional hookah smoking.

For a refresher, a hookah (also referred to as narghile, argileh, shisha, hubble-bubble, and goza) is a water pipe that people use to smoke different types of flavored tobacco or molasses. Usually, there’s water in the base, and the tobacco or molasses are put in the bowl of the pipe. Aluminum foil is typically put in-between the tobacco or non-tobacco substance and burning charcoal, which is placed on top. When inhaling through the mouthpiece of the pipe, the smoke from the charcoal sifts down through tobacco (or molasses) and water, and into the mouthpiece. As some hookahs have multiple mouthpieces, the social context of hookah smoking can be quite enticing for many because the shared pipe can evoke a communal atmosphere.

Unfortunately, experts believe that non-tobacco hookah products expose people to the same amount of carcinogenic toxins found in tobacco hookah. While hookah tobacco (or non-tobacco shisha) can be bought with trace amounts of nicotine, or even be tobacco-free, most hookah devices rely on charcoal burning as the mechanism of inhalation. And so, while it’s true that you aren't inhaling tobacco smoke, the sustained burning of the charcoal carries the risk of extended exposure to harmful chemicals. Therefore, non-tobacco hookah smokers also inhale fairly large quantities of these combustion-related toxins including carbon monoxide, polyaromatic hydrocarbons, nitric oxide, and volatile aldehydes, which have been linked to health risks such as cancer. Ultimately, the messaging around non-tobacco hookah products being the healthier alternative is misleading, and the only benefit to smoking non-tobacco hookah may be the lack of nicotine.

There’s also evidence that hookah smoking’s health risks are similar to that of cigarette smoking. One study found that, in a typical hookah smoking session, participants actually inhaled more carbon monoxide than those who smoke a pack or more a day of conventional cigarettes. For more information on how hookah smoking stacks up with cigarette smoking, and some general information on hookah smoking and its history, check out Hookah pipes — More or less harmful than cigarettes? in the Go Ask Alice! archives.

Like any other decision about substance use, it’s a personal choice, hopefully one made after considering the known risks. If you have additional questions, you can try reaching out to your health care provider or tobacco cessation specialist to discuss your concerns.

Alice!

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