Draft Hookah Issue Statement—Comments Requested by December 8


By Michelle Werts posted 11-24-2014 09:14


Earlier this year, a Society of Toxicology (SOT) member proposed the need for the Society to develop an Issue Statement on hookah use. SOT Council approved the idea and formed a writing team of experts on the subject and related topics. The team (comprised of SOT members Judith T. Zelikoff, Terry Gordon, Anthony R. Schatz, Clive Meredith, Laura S. Van Winkle, and non-member Michael L. Weitzman with John B. Morris serving as Council Contact/Liaison and Michelle J. Werts as staff support) set about researching and writing an Issue Statement with a primary intended audience of hookah users and potential users (a general audience, instead of a scientific one). Drafts were exchanged with SOT Council for feedback and edits. 

The near-final draft of the SOT Hookah Issue Statement is posted below for comments by the SOT membership. Per the 2010 Issue Statement Procedure, under which the development of this statement has been occurring, SOT membership has 14 days to offer comments on this draft before it is edited and returned to Council for a final review and vote. To provide feedback on the draft, please leave a comment on this blog post or email your comments to me. All comments are due by 11:59 p.m. EST on December 8, 2014.

Hookah: Many Unanswered Safety Questions                          
J.T. Zelikoff, T. Gordon, J. Morris, A. Schatz, C. Meredith, L. Van Winkle, M. Weitzman

Since the Surgeon General’s first report on smoking, significant efforts to reduce the impact of tobacco on human health have been undertaken. Over the past 50 years, there has been a significant decline in the use of cigarettes in the US. However, many people are turning to alternative tobacco products, such as hookah, and recent studies indicate that the use of hookah water pipes is rapidly increasing among adolescents and young adults (Amrock et al., 2014; reviewed in Lauterstein et al., 2014; Schubert et al., 2014). This practice is particularly concerning, as research suggests that hookah use may actually be as addictive and harmful as cigarette use (Neergard et al., 2007; Vansickle et al., 2014).

To use a hookah waterpipe, flavored tobacco called shisha is placed in a bowl and covered with a screen upon which charcoal is placed and heated. Air is drawn through the charcoal and shisha to produce vapors and smoke which is bubbled through water before it is inhaled. Potential health effects from hookah use are not yet well understood, but there are many factors that could impact the health of hookah users or those unintentionally exposed: the inhaled smoke and vapors, secondhand smoke and its vapors, and the emissions generated from the smoldering charcoal. Some of these products, such as the sidestream smoke and charcoal emissions, may pose health hazards to individuals present during hookah smoking even if they are not smoking. In addition, workers in hookah bars may be subjected to prolonged exposure to these emitted chemicals, which could lead to a variety of health concerns (Zhou et al., 2014).

Hookahs represent a different way to smoke tobacco, but carry with them many of the same health concerns associated with cigarette smoking (Jacob et al., 2011, 2013; Helen et al., 2014). In fact, research has shown that a single water pipe session can equate to smoking about 10 or more cigarettes and yield greater levels of nicotine, tar, and carbon monoxide than conventional cigarettes (Eissenberg and  Shihadeh, 2009; Maziak, 2011). Hookah use has been linked to lung cancer (Koul et al., 2011), and loss of pulmonary function is seen in hookah smokers when compared to non-smokers (Chan et al., 2011). Volunteers exhibited pulmonary function and heart rate changes after controlled exposure to hookah smoke in the laboratory (Hakin et al., 2011). This study also showed that hookah smoking was associated with similar peak plasma nicotine levels, greater blood carbon monoxide levels, and much greater inhaled smoke volume compared to cigarette smoking. Hookah smoking has also been linked with women delivering babies of lower birth weight (Rachidi et al., 2013).

Despite the potential health concerns, users perceive hookah as a safer and less addictive alternative to cigarettes (reviewed in Lauterstein et al., 2014). Remarkably, studies demonstrate that high school and university students, who are the greatest users of hookah, in multiple countries, including the US, are unaware of the dangers of smoking hookah. Alternative tobacco products, in general, and hookah, in particular, are not subject to the same regulations as cigarettes. Hookah use is currently unregulated by the federal government, and while a growing number of local communities and states are adopting wide-ranging clean indoor air laws, in some areas, hookah bars can claim exemption from these ordinances though higher levels of carbon monoxide have been found in hookah bar patrons than in those visiting traditional bars where cigarette smoking occurs.

To help inform policymakers and the public of the potential health effects associated with hookah use, studies that measure the composition of indoor air where hookah is smoked are needed. Such research will serve to better define the indoor air conditions and exposure levels in hookah bars and potentially provide a basis for additional studies, as well as to provide a target measurement for possible reductions in key emissions. In addition, a more complete assessment of the health effects of active hookah use and secondhand hookah smoke exposure, including the potential for damaging the DNA genetic information within cells is absolutely critical (Rammah et al., 2012; Kabhour et al., 2012). Toxicology, the study of adverse effects of substances on living organisms, including the prevention and reduction of such outcomes, can help provide a framework to fully define the health impacts of hookah use. Such information will allow for the development and implementation of science-based policies regarding hookah use.  

Given the current evidence of potential harm, the misconception of many that hookah is a healthier alternative to cigarettes is concerning. Targeted science is needed to provide the public and policymakers with the necessary information so that they can make informed decisions regarding the use of alternative tobacco products based on potential health effects.


Amrock SM, Gordon T, Zelikoff JT, Weitzman M. Hookah use among adolescents in the United States: Results of a national survey. Nicotine Tob. Res. 2014. 16(2): 231-7.

Bou Fakhreddine HM, Kanj AN, Kanj NA.  The growing epidemic of water pipe smoking: Health effects and future needs. Respir. Med. 2014. 108(9): 1241-1253.

Chan A, Murin S. Up in smoke: the fallacy of the harmless hookah. Chest. 2011. 139(4): 737-738. 

Cobb CO, Shihadeh A, Weaver MF, Eissenberg T. Waterpipe tobacco smoking and cigarette smoking: A direct comparison of toxicant exposure and subjective effects. Nicotine Tob. Res. 2011. 13(2): 78-87.

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Hakin F, Hellou E, Goldbart A, Katz R, Bentur Y, Bentur L, The acute effects of water-pipe smoking on the cardiorespiratory system. Chest. 2011. 139: 775-781.

Jacob P III, Abu Raddaha AH, Dempsey D, Havel C, Peng M, Yu L, Benowitz NL. Nicotine, carbon monoxide, and carcinogen exposure after a single use of a water pipe. Cancer Epidemiol. Biomarkers & Prev. 2011. 20(11): 2345-2353.

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1 comment


11-25-2014 08:48

Request for Additional Risk Assessment Language

I think there are too many New Yorkers on this issue statement committee!  Joking Aside, I applaud the issue statement committee to take on the general issue of tobacco products.  Having chaired a past issue statement (Gulf Oil Spill) I understand the challenges of working on these.  As a Society, I think it is important that we balance the need for ongoing science and discovery of research with fair and balanced weight of evidence, as well as evidence based appraoches to policy making.  The statement appears to have a tone of we need to fund more academic research to show how bad this stuff really is.  Tobacco industry is also part of the SOT as stakeholders, and producers of consuming something that has been part of the human experience for 2000+ years.  In the second to the last paragraph, I suggest the term "risk" be included, so it is clearer that we are considered both "how bad"? AND "how much"? together; I am constantly frustrated that the media doesn't put these concepts together when addressing the public,.. at least we can try here.  Hope this is helpful, I'll definitely think about this while I enjoy my cigar over the thanksgiving weekend!  Cheers!  Feel free to contact me if I can help with the language. 

Sol Bobst, PhD, DABT