A hookah, also known as shisha and nargile, is a waterpipe used for smoking flavored tobacco. The tobacco used in hookahs is typically shredded tobacco leaf flavored with molasses, honey or dried fruit. This sweetened tobacco product is generally called shisha in the United States. The popularity of hookah establishments (often referred to as “bars” or “lounges”) has grown in the United States, particularly in cities with large Middle-Eastern communities and in areas with significant young adult populations, such as near college campuses. Hundreds of hookah bars now operate in the United States, with new establishments opening every month.

The health risks associated with hookah smoking are generally thought to be greater than those of cigarette or cigar smoking. Hookah smoke contains significant amounts of nicotine, tar, heavy metals, and carcinogens. Waterpipe smoke may also contain charcoal or wood cinder byproduct carcinogens and carbon monoxide. An unfortunate myth persists that hookah use is less damaging to health than cigarette smoking because the water filtration system and extended hose serve as filters for harmful agents. In fact, the water filtration system only cools the smoke, allowing the user to inhale greater amounts of smoke over a longer period of time. A typical hookah session may last for an hour or more and this period of sustained inhalation increases exposure to carcinogens and is similar, in result, to smoking up to 100 cigarettes.

Legal Issues

A key legal issue relating to hookah smoking is whether such an activity would be covered under a clean indoor air statute or ordinance. For example, Illinois and New Mexico include “hookah” within a definition of the term “smoking” but then exempt those hookah establishments as retail tobacco or specialty stores. Illinois requires that a hookah establishment derive more than 80 percent of its gross revenue from the sale of tobacco products and not sell food or alcoholic beverages. New Mexico exempts hookah lounges under a retail tobacco store exemption, but also requires that alcoholic beverages be prohibited. Maine expressly includes hookahs under the definition of a tobacco specialty store exemption so long as that store was licensed prior to January 1, 2007 and the preparation or consumption of food or drink on the premises is prohibited.

Other statewide smoke-free regulations do not address hookah smoking specifically. Approximately fifteen states, including Puerto Rico and Washington, D.C., contain retail tobacco store exemptions that could possibly cover hookah bars. Whether a hookah establishment might fall under such an exemption depends largely on the language of the exemption and the characteristics of the hookah bar in question. At least seven state smoke-free laws contain “smoking bar,” “tobacco bar” or “cigar bar” exemptions that could also include hookah establishments. This again depends primarily on the language of the exemption. For example, a hookah establishment in Massachusetts might fit under a “smoking bar” exemption so long as certain requirements are met, such as incidental sale of food or alcohol, prohibition on entry of minors during business hours, and valid permit requirements under Massachusetts law.

Key Research

• Cobb, C.; Ward, K.D.; Maziak, W.; Shihadeh, A.L.; Eissenberg, T. Waterpipe Tobacco Smoking: An Emerging Health Crisis in the United States, American Journal of Health Behavior, 34(3):275-285 (May-June 2010). Examines the prevalence and potential health risks of waterpipe tobacco smoking in the U.S.
• Aljarrah, K.; Ababneh, Z.Q.; Al-Delaimy, W.K., Perceptions of hookah smoking harmfulness: predictors and characteristics among current hookah users, Tobacco Induced Diseases 5(1):16 (2009). Surveys hookah users in the San Diego, California, area to determine their perceptions of the health hazards of hookah smoking. A majority of those surveyed (58.3 percent) believed that hookah smoking was less harmful than smoking cigarettes.
• Knishkowy, B. & Amitai, Y., Water-Pipe (Narghile) Smoking: An Emerging Health Risk Behavior, Pediatrics, 116:113–19 (2005). A study finding that the concentration of harmful chemicals in shisha tobacco is generally as high as or higher than the concentration of such chemicals in cigarette tobacco, and that hookah smokers are likely to confront the same health problems as cigarette smokers.
• Maziak, W. et al., Tobacco Smoking Using a Waterpipe: A Re-emerging Strain in a Global Epidemic, Tobacco Control 3:327-33 (2004). A study finding preliminary evidence linking hookah smoking to a variety of tobacco-related health problems such as heart disease and pregnancy complications, and concluding that more evidence is necessary to fully understand the spread of hookah use and its health implications.
• El-Hakim Ibrahim, E. & Uthman Mirghani, A.E., Squamous cell carcinoma and keratoacanthoma of the lower lips associated with "Goza" and "Shisha" smoking, International Journal of Dermatology 38:108-10 (1999). A study finding that hookah smoking may cause obstructive lung disease in smokers and predispose smokers to oral cancers.
• Nuwayhid, I. et al., Narghile (Hubble-Bubble) Smoking, Low Birth Weight and Other Pregnancy Outcomes, American Journal of Epidemiology 148:375 (1998). A study finding that children born from pregnancies in which the mother smoked hookah are more likely to have low birth weights and respiratory distress than children born from nonsmokers.

Select Policies

• Smoke Free Illinois Act. This act contains a variety of provisions both impliedly restricting the usage of hookahs in certain areas while allowing the usage of hookahs in certain establishments provided that those establishments meet certain statutory requirements.
• The Attorney General of Maryland has stated that although there is no hookah bar provision in the smoke-free air act, as long as the primary activity of the hookah bar is to sell tobacco, it would be exempt. Maryland also enables county to grant waivers to businesses to allow smoking if that business can show some sort of hardship.

Resources

• Hookah Bars. Americans for Nonsmokers Rights website. Compilation of news articles and research on hookah bars and smoking.
• Michael F. Strande, Legal Resource Center for Tobacco Regulation, Litigation & Advocacy, University of Maryland, Power Point Presentation: Confronting the Emerging Threat of Hookah Bars (Mar. 26, 2008). Presentation covering the basic concept of hookah smoking, health issues related to hookah smoking, and ways states and municipalities can regulate and restrict the proliferation of hookah establishments.
• American Lung Association, An Emerging Deadly Trend: Waterpipe Tobacco Use (Feb. 2007). Report outlining the way hookahs function, contemporary scientific information on hookah, common perceptions of hookah users, marketing trends, and state regulation of hookah.
• U.S. Dep’t of Health of Health & Human Services, Ctrs. for Disease Control & Prevention, Hookahs Fact Sheet (April 2007). Brief discussion of the health issues related to hookah smoking with links to data sources and other information related to tobacco control.
• American Cancer Society, Waterpipe (Hookah) Factsheet (2005). Fact sheet detailing the health problems related to hookah smoking.
• World Health Organization, WHO Study Group on Tobacco Product Regulation, Advisory Note: Waterpipe Tobacco Smoking: Health Effects, Research Needs and Recommended Actions by Regulators (2005). Study detailing the health problems associated with hookah smoking and provides suggestions to regulators on how to properly restrict and contain hookah usage.