Why Hookah Pipes Aren’t a Healthier Way to Smoke

June 19, 2016| Von Ross Campbell | Critical Illness, Life | English

Shisha lounges, where people smoke hookah waterpipes, may be growing in popularity in some countries, following restrictions on tobacco smoking in public areas. Many people incorrectly believe smoking this way is less harmful than using cigarettes, especially with non-tobacco products for use in hookah pipes often marketed as a “healthier” alternative to flavoured tobaccos. But this method of smoking itself poses significant health risk.

Unlike cigarettes, tobacco in hookahs does not burn continually. Instead, lit charcoal is placed in a bowl at the top of the pipe. Air drawn through a mouthpiece activates the charcoal burning the tobacco and creating smoke. The smoke is cooled as it passes through a water reservoir at the base of the pipe. Contrary to popular belief, the water does not render the toxic components harmless.

Smoking shisha exposes people to the known harms of tobacco. Charcoal makes tobacco burn at very high temperatures, and this increases the levels of carbon monoxide and cancer-causing chemicals emitted. All hookah smoke contains carbon monoxide (CO) that increases cardiovascular risk. It also delivers polycyclic aromatic hydrocarbons (PAH) that increase cancer risk and volatile aldehydes (VA) that cause lung disease - much the same harmful toxins as tobacco smoke.

Hookah smoking involves deep inhalation and frequent puffing over prolonged periods. A typical session has users taking 200 puffs; over 10 times the number needed to smoke a single cigarette. They inhale around 90,000 millilitres (ml) of smoke from a pipe compared to 500-600 ml from smoking a cigarette - and that could be up to 200 times more.

a man smoking shisha

Shisha smokers risk nicotine addiction, cancer of the mouth, oesophagus, stomach and lung as well as reduced respiratory function. Even herbal products consumed this way mean exposure to the by-products of charcoal combustion. Despite the dangers, the attraction of this centuries-old practice is growing - particularly amongst young people, perhaps due to the communal aspect of the experience.

The variety of nicotine sources, from e-cigarettes to hookah pipes, makes identifying users a priority and a challenge for underwriters. Regular smokers of tobacco in hookah pipes can be identified through a question on smoking that asks for disclosure of all sources and kinds of tobacco. A cotinine test of a waterpipe smoker would also most likely prove positive. However, those who prefer to consume non-tobacco products by this method will only be spotted if hookah pipe use is specifically questioned.


  1. Cobb CO et al. Waterpipe tobacco smoking: an emerging health crisis in the United States, American Journal of Behavior 2010;34(3):275-85.


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