Photo: JanKrömer

Risks, regulation, and popular images of smoking waterpipes

Pro-tobacco forces have taken repetitive and expensive hits in the past several decades. While nearly 45 percent of Americans smoked cigarettes in the 1950s, only 18.1 percent do today. In post-Bloomberg New York City, cigarettes are taxed at 75 percent. Now hookah, after years of hiding in dark and smoky corners, is about to get pulled into the crossfire between two formidable forces: big tobacco and big government.

In April, the FDA proposed to regulate the “wild wild west” of e-cigarettes, hookah, cigars, and pipe tobacco.  The 75-day public comment period on the FDA’s proposed rule ends July 9, 2014.

What is hookah?

As I picked my way through the souks of Marrakesh a few months ago, I spotted eager tourists stuffing their bags with hookahs of all shapes and sizes – little cheap ones dotted with elephants, large ornate golden multi-pipe life-of-the-party versions.

Hookahs are waterpipes used for smoking flavored tobacco with a head, a metal body, a water bowl and a flexible hose with a solid mouthpiece. They can be used by one person or a group, which either passes around a single hose or uses multiple hoses simultaneously. The most popular hookah mixture in the United States – what you’re bound to wind up with if you don’t know what you’re asking for – is about 30 percent cut tobacco with 70 percent  honey, molasses and various flavorings.

Although tobacco is tobacco, there has never been a widespread public health campaign around hookah use in the United States. Certainly, part of this has to do that hookahs are used privately, either in the comfort of lounges or in the home. Nobody’s walking down the street blowing mango-flavored hookah smoke into your kid’s stroller or up in your hairdo. Hookahs have largely found shelter from the ire of anti-cancer lobbies, striking many as a “live and let live” kind of hobby.

Appeal to young people

In 2009, in an effort to curb teen smoking, the United States implemented the Family Smoking Prevention and Tobacco Control Act. This multi-pronged act put an end to the sale of clove, fruit and candy-flavored cigarettes including the popular brand Djarum, owner of the Splash and Black labels. It banned youth-focused marketing, anything the FDA deemed fun or pool-partyish or watermelon-with-a-smiley-face-ish.

At the time, FDA Commissioner Dr. Margaret A. Hamburg said that “Almost 90 percent of adult smokers start smoking as teenagers. These flavored cigarettes are a gateway for many children and young adults.” But amid the crackdown on cloves and candied cigars, hookahs snuck under regulation.

Yet a hookah’s little coils of flavored tobacco – also called “shisha” – come in tween-friendly flavor combinations like mint chocolate chili, white gummy bear, prickly pear and – most terrifyingly – blueberry muffin.

And young people are buying: a 2011 study revealed that 40.3 percent of college students had smoked hookah, even though 22 percent of the same group had never tried a cigarette. From 2011 to 2012, hookah use among all high school students rose from 4.1 to 5.4 percent. And in a national survey of high school seniors, 17 percent reported smoking a hookah within the past year.

teenagers at hookah lounge

Although many states have banned smoking in public places, hookah lounges have found a loophole. Photo: Wikimedia Commons

Best of all, for kids, it’s cheap – you can rent a hookah with a group for $10 – $20 an hour and get out of your friend’s car smelling like a weird melon rather a parent-alarming ashtray. You can also usually hang out at a hookah lounge if you’re under 21. Hookah advertising is often conducted through youth-friendly, adult-avoidant channels such as Tumblr and YouTube.

A 2013 analysis of YouTube videos revealed that only 24% of cigarette-related videos were used to glorify their use, while 92% of hookah-related videos did so.

Risks of hookah use

How does hookah compare to smoking cigarettes? As water absorbs less than 5 percent of the nicotine, both shisha and tobacco used in cigarettes can prove addictive. The World Health Organization estimates that one hookah tobacco smoking session delivers 50–100 times the smoke volume of a single cigarette.

I shared this number with a few hookah smokers and they were all dubious; “it doesn’t feel like that,” “no one smokes a hookah for an hour straight,” “if I smoked 100 cigarettes in a sitting I wouldn’t be able to get out of bed in the morning.”

According to the CDC, other risks associated with hookah use include:

-Heat sources used to power waterpipes (like wood cinders and charcoal) can cause exposure to additional carbon monoxide, metals and cancer-causing chemicals.

-Passing the pipe around can contribute to the spread of infectious diseases from herpes to hepatitis.

-Babies born to women who smoked hookah daily while pregnant weigh less at birth (at least 3.5 ounces less) than babies born to nonsmokers.

-In one study, researchers found that like smoking cigarettes, smoking hookah for only one session led to dysfunction in cardiac regulation, which is “implicated in adverse cardiovascular health outcomes.”

Yet the majority of hookah smokers believe smoking hookah is significantly safer than smoking cigarettes.

Hookah regulation to tighten; loopholes will remain

Hookah use remains understudied by public health researchers and under-represented in public dialogue about tobacco and health; anti-obesity, anti-cigarette and anti-breast cancer lobbyists have all done a much better job of steering the national conversation.

While 28 states now enforce smoking bans in all enclosed public places, hookah lounges are able to apply for exemption permits. These permits were originally created for “tobacco retail establishments” – smoke shops where people were supposed to be able to test the tobacco and paraphernalia they intended to purchase.

The promotion of hookah lounges is also a largely unregulated space. In a recent study of 144 hookah establishments promoted on websites, none required age verification, under 1 percent included a tobacco warning on the first page and 4 percent included a warning on any page.

University of Pittsburgh’s Dr. Brian Primack on advertising hookah establishments on the Internet

For the moment, while hookah’s lack of regulation is undesirable from a public health perspective, it is understandable. As stories of heroin overdose and tainted drug batches spread throughout the Northeast, it is difficult to make a compelling argument for funneling limited resources into the fight against smoking hookah. Many who do so do so infrequently. You can’t overdose on hookah. In the short term, at worst, you’ll get nauseous and a cough – the age-old teen smoker’s punishment. It could kill you, but it won’t do so quickly.

In late April, the FDA moved to crack down on e-cigarettes, pipes, hookahs and cigars. The rule includes a firm, nationwide age limit of 18 years old for buying these products. They’ll be branded with nicotine-warning labels and will be prohibited from using “modified risk descriptors” like light, low and mild in their advertising. You won’t be able to buy them in vending machines.

For health organizations like the Mayo Clinic, the American Lung Association and the Centers for Disease Control and Prevention, this will represent a major win. But unless the tobacco retail establishment loopholes are closed, hookah lounges will continue to open unabated.

Recommended Resources

CDC Fact Sheet: Hookahs

Waterpipe Tobacco Smoking: Health Effects, Research Needs, and Recommended Actions by Regulators by the WHO Study Group on Tobacco Regulation

Hookah: Myths and Truths (One-page handout)



Melissa Batchelor Warnke is a writer, editor and researcher. She studies subcultures, memorial design, recovery & badass women. She tweets @thewarnke.