Hookah Dangers Smolder Beneath New Regulations

Hookah bars are on the rise around the world despite their being associated with many health risks.

Hookah use actually began centuries ago in ancient Persia and India and has recently enjoyed global growth in popularity, with successful smoking lounges popping up in the United States, Britain, France, Russia, the Middle East, and elsewhere.1

Hookahs (also known as narghile, argileh, shisha, hubble-bubble, and goza) are water pipes that are used to smoke flavored tobacco. Smoking hookah is a highly social activity, and generally, the same mouthpiece is passed around among users of a single hookah. An unfortunate consequence of this is, of course, that it can easily spread infections such as hepatitis and herpes.

Perhaps because of the variety of flavors and the pleasing aesthetics of hookah pipes, it’s often overlooked that hookah smoking has many of the same health risks as cigarette smoking. The smoke produced from hookahs is at least as toxic as cigarettes.1 Typically, a 1-hour hookah session involves inhaling 100 to 200 times the volume of smoke from a single cigarette.2 Also, the charcoal used to heat the tobacco can cause health risks by producing high levels of carbon monoxide, metals, and carcinogenic chemicals. Additionally, babies born to hookah smokers are at an increased risk of low birth weight and respiratory illnesses.

Hookah smokers may be at an increased risk of developing some of the same diseases as cigarette smokers including the following:1

  • Oral cancer
  • Lung cancer
  • Stomach cancer
  • Esophageal cancer
  • Gastric cancer
  • Reduced lung function
  • Decreased fertility

According to a CDC study, hookah use increased among middle and high school students from 2011 to 2015. In 2015, 2% of middle school students reported that they had used hookah in the past 30 days, an increase from 1% in 2011. Also, 7.2% of high school students reported in 2015 that they had used hookah in the past 30 days, an increase from 4.1% in 2011.3

As of August 2016, the FDA began regulating all tobacco products, including hookah.2 Hookah “components” and “parts” that are regulated include but aren’t limited to the following:2

  • Hookah (waterpipe)
  • Flavor enhancers
  • Hose cooling attachments
  • Water filtration base additives
  • Charcoal made from wood, coconut shell, or other material
  • Bowls, valves, hoses, and heads

Beginning in 2018, all hookah tobacco products must include the following warning statement: “WARNING: This product contains nicotine. Nicotine is an addictive chemical.”

The following FDA rules apply to all hookah and pipe tobacco sales:2

  • The photo ID of everyone under age 27 attempting to purchase hookah products must be checked.
  • Hookah tobacco can only be sold to customers 18 years of age and older.
  • Free hookah samples are prohibited.
  • Hookah products cannot be sold in a vending machine unless it’s an adult-only facility.

Pharmacists can play an important role in communitywide education programs regarding the dangers of using hookahs and update other health care professionals on the new regulations. Educating middle and high school students is a great way for pharmacists to help reduce hookah use. Pharmacists should also report any adverse effects associated with hookah use to the FDA.


  • CDC. Hookahs. CDC website. cdc.gov/tobacco/data_statistics/fact_sheets/tobacco_industry/hookahs/.
  • FDA. Hookah tobacco (shisha or waterpipe tobacco). FDA website. www.fda.gov/TobaccoProducts/Labeling/ProductsIngredientsComponents/ucm482575.htm.
  • CDC. Youth and tobacco use. cdc.gov/tobacco/data_statistics/fact_sheets/youth_data/tobacco_use/.