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Produced by Constantina Karambelas and Fahiemah Al-Ali

Produced by Connie Karambelas & Fahiemah Al-Ali

The hookah trend is hot in Chicago. Over 30 hookah establishments thrive in the city alone, and business doesn't show any signs of slowing. But despite its social nature, smoking hookah comes with its own health risks, and Chicagoans weigh in on their steamy habit.

Health effects of hookah, spot on or smoke and mirrors?

by Fahiemah Al-Ali and Connie Karambelas
June 03, 2010



The hookah, traditional to the Middle East, has experienced widespread popularity in cities across the United States.

Graph 1

Data courtesy of "Perceptions of hookah smoking harmfulness" study.


Data courtesy of "Perceptions of hookah smoking harmfulness" study.

You probably can’t even pronounce it, but you’ve likely encountered this international item in one form or another.

It’s slender, social and picking up steam – literally.  It’s the narghile, more commonly referred to as hookah, and this national trend is hot in Chicago.

According to the Chicago Hookah Review website, an outlet that promises to be the most extensive list of hookah establishments in Chicago – 30 businesses thrive in the city alone.  

The intercontinental import is especially popular in college towns, noted Dr. Jon Ebbert, associate director of the Medicine Nicotine Dependence Center at the Mayo Clinic in Rochester, Minnesota.

“Because of that shared social context,” he said, “people go into these hookah bars together and they may have their own little mouthpieces and they sit around and share an eight-tubed water pipe – it’s an experience.”

But sharing isn’t always caring when it comes to the hookah experience, and it might not be an informed decision either, says Dr. Wael Al-Delaimy, chief of the Division of Global Health at the University of California, San Diego.

Al-Delaimy was one of the researchers who conceived a study that assessed user beliefs – not the health risks – associated with the harmfulness of smoking hookah.

Published in the journal Tobacco Induced Diseases, the study surveyed 235 hookah users from August–September 2008 in San Diego cafés that provided hookah to customers.

The researchers found that the majority of frequent hookah users – 58 percent – were more likely to believe that hookah is less harmful than cigarettes.

While study researchers didn’t question respondents as to why they perceived hookah as a healthier alternative to smoking, Al-Delaimy speculated that this was linked to the belief that hookah smoke is “filtered” through water before it is smoked, giving it a cooler feeling in the mouth and reduced irritation as opposed to cigarettes.

But it’s all smoke and mirrors, a misconception, said Ebbert.

The smoke filtration is a fallacy, and the real issue is the inhalation factor, he said.

“The biggest concern about hookah smoking is that [users] are inhaling a larger volume of smoke than they do with a cigarette,” said Ebbert. “There is good data out there proposing that for the amount of exposure of any given hookah session, there is probably a higher exposure to harmful substances.”

But Kamal Chaouachi, a Paris-based hookah and tobacco researcher with a Ph.D. in tobacco science, isn’t buying it.

While he has published critical reviews of numerous hookah studies, he doesn’t endorse hookah smoking or dismiss its harmful effects.

Instead, Chaouachi asserts that some hookah research not only exaggerates public health effects, but it also contains serious flaws in scientific methodology.

For example, in a review in the International Journal of Environmental Research and Public Health, he wrote that the widely accepted Federal Trade Commission norms that are used in the laboratory to test the harmful effects of hookah smoking are unrealistic.  

The machine used during the five-minute laboratory session is used to mimic an actual cigarette smoker with two puffs after every one-minute interval, said Chaouachi.

“However, and by a striking contrast, the ‘waterpipe’ used in the laboratory was based on 171 steady puffs drawn every 17 seconds, i.e. for one full hour,” he wrote.

Chaouachi questions the feasibility of any hookah smoker taking one puff every 17 seconds during an hour-long social hookah session – thus making any numerical toxicity data and health warnings resulting from hookah experiments potentially inflated.

Furthermore, take the aforementioned California-based hookah perception study.

Chaouachi’s letter to the editor of the journal Tobacco Induced Diseases, outlined several inconsistencies he believed were printed in the publication, including a statement made in the study: “When compared to cigarette smoking … hookah smoke also contains 36 times the amount of nicotine.”

“In fact, this elevated figure [36] is not that for nicotine,” he wrote.

“There is a growing consensus among tobacco control researchers that one hookah session would not deliver more nicotine than one single cigarette.”

And while Al-Delaimy and other members of his team acknowledged their miscalculation (36 should have been 3.8) in a response to Chaouachi, they didn’t agree with his claim that less nicotine would be delivered during a hookah session as opposed to smoking a cigarette.

But the hookah versus cigarette argument misses the underlying point, said Dr. Michael Siegel, an anti-smoking researcher and professor at Boston University’s School of Public Health:

Both hookah and cigarettes pose health risks.

While Siegel validates Chaouachi’s critiques on the premise of equally comparing the risks of hookah to those of cigarettes, he says it’s more important to educate the public about the harms of both forms of smoking.

Ebbert echoes Siegel’s stance on raising awareness, but said he did not know that scientific methodology performed during hookah studies was being questioned.

“I mean part of what we struggle with is that it’s easy to criticize medical research that is done,” he said.

“So that’s my challenge of anyone who criticizes our work.  It’s not our work personally, but it’s the tobacco control community, who develops a corpus of knowledge, that yeah, you can attack, but then I challenge you to do it better, that’s what we really need – better research.”