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Waterpipe Tobacco Smoking: AnEmerging Health Crisis in the United StatesCaroline Cobb, MS; Kenneth D. Ward, PhD; Wasim Maziak, MD, PhD;Alan L. Shihadeh, ScD; Thomas Eissenberg, PhD

Caroline Cobb, Graduate Student, Departmentof Psychology, Virginia Commonwealth University,Richmond, VA. Kenneth D. Ward and WasimMaziak, Associate Professors, Department of Healthand Sport Sciences and Center for CommunityHealth The University of Memphis, Syrian Centerfor Tobacco Studies, Aleppo, Syria, Memphis, TN.Alan L. Shihadeh, Associate Professor, Departmentof Mechanical Engineering, American University ofBeirut, Lebanon. Thomas Eissenberg, Professor,Department of Psychology and Institute for Drugand Alcohol Studies, Virginia Commonwealth Uni-versity, Syrian Center for Tobacco Studies, Aleppo,Syria, Richmond, VA.

Address correspondence to Dr Eissenberg, De-partment of Psychology and Institute for Drugand Alcohol Studies, Virginia CommonwealthUniversity, Box 980205, Richmond, VA 23298.E-mail: [email protected]

Objective: To examine the preva-lence and potential health risksof waterpipe tobacco smoking.Methods: A literature review wasperformed to compile informationrelating to waterpipe tobaccosmoking. Results: Waterpipe to-bacco smoking is increasing inprevalence worldwide; in theUnited States, 10-20% of someyoung adult populations are cur-rent waterpipe users. Dependingon the toxicant measured, a single

waterpipe session produces theequivalent of at least 1 and asmany as 50 cigarettes. Miscon-ceptions about waterpipe smokecontent may lead users to under-estimate health risks. Conclusion:Inclusion of waterpipe tobaccosmoking in tobacco control ac-tivities may help reduce its spread.

Key words: waterpipe tobaccosmoking, prevention, adolescentbehavior

Am J Health Behav. 2010;34(3):275-285

Tobacco use causes many of theworld’s leading lethal ailments, in-cluding cardiovascular disease,

chronic obstructive pulmonary disease,and lung cancer.1 In the United States,tobacco smoking remains the leading pre-ventable cause of death, even as consid-erable success has been achieved in curb-

ing the tobacco epidemic over the past 20years.2 This success is threatened byalternative methods of tobacco use, in-cluding waterpipe tobacco smoking.3,4

Waterpipe tobacco smoking is a centu-ries-old tobacco use method with an am-biguous origin5 and links to the countriesof southwest Asia and north Africa. Al-though known by many different names(eg, hookah, narghile, shisha), the termwaterpipe has been used for the last 2decades in the English language scien-tific literature6-10 to refer to any of a vari-ety of instruments that involve passingtobacco smoke through water before in-halation. Contrary to popular belief thatwaterpipe tobacco smoking is less lethalthan cigarette smoking,9,11 emerging re-search indicates that both involve com-parable health risks3,4,12 including nico-tine/tobacco dependence.13,14 In addition,waterpipe tobacco smoking may be, forsome individuals, a precursor to cigarettesmoking.15-17 All of these issues are rel-evant to the United States, wherewaterpipe tobacco smoking appears to beincreasing in popularity. Thus, this re-view addresses this emerging tobacco

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use method in the United States by high-lighting current data regarding its preva-lence and potential health effects, as wellas the knowledge, beliefs, and attitudesassociated with, and potentially fueling,the spread of this tobacco use method.Our goals include increasing awareness,stimulating research, influencing policy,and developing effective prevention andtreatment interventions.

What Are Waterpipes and How AreThey Used to Smoke Tobacco?Although composition details may dif-

fer by culture, tobacco waterpipes mostoften seen in the United States have afired-clay head, metal body, glass or acrylicwater bowl, and leather or plastic hose(Figure 1). The bowl is partially filled withwater and the head is filled with moist-ened tobacco upon which a lit piece of

Figure 1A Waterpipe Prepared for Tobacco Smoking, Including Perforated

Foil Separating the Charcoal from the Tobacco That Has BeenPlaced in the Head

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charcoal is placed (tobacco and charcoalare often separated by perforated alumi-num foil). The smoker inhales throughthe hose, thus drawing air over the burn-ing charcoal, heating the tobacco, andproducing smoke that travels through thebody of the waterpipe, the water, and thehose to the user.18 The most popular typeof waterpipe tobacco is called maassel(also known as shisha tobacco), a wetmixture of tobacco, sweetener, and flavor-ings. Maassel comes in many flavors,including fruit and candy, and it producesan aromatic smoke that may be particu-larly appealing to youth.19 Waterpipe char-coal products range from traditionalearthen kiln charcoal to quick-lightingproducts that are particularly common inthe United States.20

Relative to a single cigarette, com-pleted in about 5 minutes,21 a singlewaterpipe use episode typically lasts forabout 1 hour.18 Recent technical innova-tions22-24 confirm this duration and alsoprovide a more detailed analysis ofwaterpipe tobacco smoking episodes. Asseen in Table 1, data collected from actualwaterpipe tobacco smokers in naturalsettings show that a waterpipe use epi-sode typically involves almost 200 puffs,with an average puff volume exceeding500 ml.22,24 Thus, compared to a cigarette,which involves inhalation of approximately500-600 ml of smoke (ie, 10-13 puffs ofabout 50 ml, on average25,26), a singlewaterpipe use episode involves inhala-tion of approximately 90,000 ml ofsmoke.22,24 Although these detailed pufftopography data are based on waterpipetobacco smokers in Lebanon, the dura-tion of waterpipe use episodes has beenexplored (via self-report) in surveys of USwaterpipe tobacco smokers, with as manyas 44% reporting episodes of 60 minutesor longer.20

Waterpipe Tobacco Smoking in theUnited StatesWaterpipe tobacco smoking is often as-

sociated with southwest Asia and northAfrica but, in recent years, has spreadacross the globe and to the United States.In this country, several lines of evidencesuggest that waterpipe tobacco smoking isbecoming more common, especially oncollege campuses. First, in April 2004,Smokeshop magazine (a 30- year-old tradejournal serving the tobacco industry) re-ported that 200-300 new waterpipe caféshad opened in the United States since1999 and that these cafés were “often nearcollege campuses.”27 Second, recent pressreports support the idea that the UnitedStates is in the early stages of a waterpipeepidemic among its college-age popula-tion: waterpipe use has been reported in atleast 33 states, with most reports comingfrom cities with a large university.28-35 Asone recent letter in the American Journal ofPublic Health noted: “In Pittsburgh, 4 hoo-kah bars have opened since 2003, each nomore than 5 miles from the campuses ofCarnegie Mellon University and the Uni-versity of Pittsburgh. Hookahs have be-come commonplace at fraternity parties atthese universities. . .”36

These anecdotal reports are beginningto be corroborated by survey data fromindividual universities across the coun-try (Figure 2, Panel B). For example, in aconvenience sample survey of 411 JohnsHopkins University freshmen (100% <age23, 48% women, 58% white, 93% US citi-zen), 15.3% reported past 30-day waterpipetobacco smoking.11 In another conve-nience sample survey of 744 VirginiaCommonwealth University students (93%<age 23, 65% women, 43% nonwhite, 92%US citizen), 20.3% reported past 30-daywaterpipe use.38 In the only study of a UScollege population to use random sam-

Table 1Mean Puff Topography for Waterpipe Users and Cigarette Smokers

Waterpipe CigaretteTopography variable N = 2024 N =5222 N = 3025 N = 5626

Puff number 178 171 10.0 12.7Puff volume (ml) 590 530 51.0 48.6Puff duration (s) 2.8 2.6 1.4 1.5Interpuff interval (s) 15.2 15.5 30.7 21.3


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pling procedures, 40.5% of 647 studentswho responded to an e-mail survey re-ported ever using a waterpipe to smoketobacco, with 9.5% reporting waterpipetobacco smoking in the past 30 days.39,40

Thus, especially among university stu-dents, waterpipe tobacco smoking hasbecome remarkably common in theUnited States. The spread of waterpipetobacco smoking may be attributable, atleast in part, to the ready commercialavailability of flavored tobacco and quick-lighting charcoal.9 In the United States,these and other waterpipe-related prod-ucts commonly are purchased via theInternet.20

Recent work in Southwest Asia and theUnited States suggests that some indi-viduals begin smoking tobacco using awaterpipe at a young age. For example, ina survey of 2443 Lebanese students (11 to17+ years old; M=15) from public and pri-vate secondary schools in greater Beirut,64.9% reported that they had triedwaterpipe at some point in their life, and25.6% reported past 30-day use.41 Also,among 388 Israeli schoolchildren aged12-18, 41% reported current waterpipetobacco smoking, and 22% reported thatthey used a waterpipe to smoke tobaccoevery weekend.42 In the United States, asurvey of 1671 Arab American adoles-cents found that 26.6% reported ever useof a waterpipe, and by the age of 14, moreadolescents had tried waterpipe than ciga-

rettes (23% vs 15%, respectively).43 Manywaterpipe users in this survey reportedthat they first used the waterpipe beforethe age of 10.43 In a study of a conveniencesample of 1872 14- to 18-year-olds in theUS Midwest, 16.7% Arab American youth,and 11.3% non-Arab youth reported past-month waterpipe use.44 Clearly, culturalfactors may be important in understand-ing waterpipe use among these ArabAmerican populations, and more workaddressing this issue is necessary.Waterpipe tobacco smoking is also sur-prisingly common in more diverse popu-lations:, among 6594 Arizona students(grades 6 thru 12) who responded to theYouth Tobacco Survey, 7.3% of 12th grad-ers and 3.5% of all students reported past30-day waterpipe use.45 All of these dataaddressing youth are important because,at least for cigarette smoking, earlierinitiation is associated with longer dura-tion of smoking and increased risk ofnicotine dependence and deleterioushealth effects.46 Moreover, waterpipe to-bacco smoking in the United States maybe introducing tobacco to an otherwisetobacco-naïve group of adolescents andyoung adults. In Pittsburgh, 35.4% of uni-versity students who use a waterpipe hadnever smoked a cigarette.39

The fact that many waterpipe tobaccosmokers are otherwise tobacco naïve isworrisome, in part because waterpipe to-bacco smoking may become a gateway to

Perc

ent (

%)

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A BNorth America

Baltimore, MDN = 411

Richmond, VAN = 744

Pittsburgh, PAN = 647

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Aleppo, SyriaN = 587

Beirut, LebanonN = 416

Lifetime WP usePast 30-day WP use

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Richmond, VAN = 74438


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Richmond, VAN = 744


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Figure 2Percent of Respondents from Locations in Southwest Asia19,37

and North America11,38,39 Reporting Lifetime and Past 30-dayWaterpipe (WP) Tobacco Smoking

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initiation of cigarette smoking.15 Such aprospect is plausible given that waterpipetobacco smoking is time-consuming andlargely sedentary: active individuals whoenjoy the effects of smoking tobacco witha waterpipe may turn to cigarettes for amore convenient and mobile smokingmethod. Evidence from cross-sectionalstudy of Arab American adolescents showsthat the odds of experimenting with ciga-rettes were 8 times greater for those whohave ever smoked tobacco using awaterpipe.43 In a population-based study ofyoung adult US military recruits, waterpipeusers were more likely than nonusers toplan to initiate cigarette smoking in thenext year.16 Thus, preliminary data sug-gest that the waterpipe can become avector to highly lethal and addictive ciga-rette smoking. There is less evidencethat waterpipe tobacco smoking is associ-ated with marijuana use: in a survey of201 US waterpipe tobacco smokers, 64.2%reported not having used marijuana inthe past 30 days, and only 10.4% reportedthat they smoked marijuana and tobaccoin the same waterpipe.20

To What Toxicants Are WaterpipeUsers Exposed?For some tobacco smoke toxicants (eg,

nicotine, carbon monoxide, or CO), thesmoke content and user toxicant expo-sure associated with waterpipes is atleast comparable to that of cigarettes.10,47,48

In terms of smoke toxicant content, whenwaterpipe tobacco smoke is generated bya machine that is programmed to imitatethe puff parameters of actual waterpipeusers, substantial amounts of nicotine,CO, and tar (nicotine-free dry particulatematter) can be measured in the smoke.18,23

As Table 2 shows, the levels of CO and tarproduced by a single waterpipe use epi-sode are substantially greater than thosefound in the smoke generated by a ma-chine programmed to smoke a singlecigarette using puffing parameters ob-served in cigarette smokers. In fact, thesedata suggest that, relative to a singlecigarette (about 500 ml of smoke, seeTable 1), a single waterpipe use episode(about 90,000 ml of smoke, see Table 1) isassociated with 1.7 times the nicotine,6.5 times the CO, and 46.4 times the tar.Although extrapolating this type of smokecontent analysis to actual cigarette orwaterpipe smokers has important limita-tions (see 23,49), these data suggest that

waterpipe tobacco smoking is likely asso-ciated with substantial toxicant exposure.

Although more research is needed, pre-liminary evidence supports the notionthat waterpipe tobacco smokers are ex-posed to a variety of smoke toxicants. Forexample, a meta-analysis of studies look-ing at waterpipe users’ exposure to thepsychoactive and dependence-producingdrug nicotine shows that daily waterpipeuse produces a urinary cotinine levelthat corresponds to a nicotine absorptionrate equal to smoking 10 cigarettes perday.48 CO, a smoke toxicant that reducesthe blood’s ability to carry oxygen, can alsobe found in waterpipe users,50 andwaterpipe-induced increases in expiredair CO may far exceed those produced bya cigarette.51,52 Indeed, in a recently pub-lished study of waterpipe users in Califor-nia, waterpipe tobacco smoking led to amean increase in expired air CO of over30 ppm,10 about 5 times that which wouldbe expected from a single cigarette.eg,25

Thus far, there has been little empiricalattention paid to users’ exposure to othertoxicants in waterpipe smoke, includinglung carcinogens23,53 and heavy metals.18,54

Recent research has shown thatwaterpipe smoke may contain a variety ofspecific toxicants found in cigarettes. Forexample, machine-generated waterpipesmoke contains alarming levels of vola-tile aldehydes such as formaldehyde, ac-etaldehyde, and acrolein, all compoundspresent in cigarette smoke.55 Anothertoxicant of interest is the isotope 210Po,which is a member of the uranium decayseries and present in tobacco and tobaccosmoke.56 Entering smokers’ bodies viainhaled smoke 210Po is capable of deliver-ing powerful radiation doses and thus

Table 2Machine-generated Smoke

Content Using Realistic PuffParameters for a SingleWaterpipe Episode and a

Single Cigarette

Toxicant(mg) Waterpipe23 Cigarette26 Ratio

Nicotine 2.94 1.74 1.7C O 145 22.3 6.5Tar 802 17.3 46.36


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radiotoxic effects to humans.56,57 Althoughthe activity concentrations of 210Po in 2forms of waterpipe tobacco may be lowerthan those in cigarette tobacco, the per-centage of 210Po released in the smokestream is still high (>39%, see 58,59). Takentogether, all of the data concerningwaterpipe tobacco toxicant content raiseimportant concerns, as decades of re-search on cigarette smokers demonstratethat prolonged exposure to these toxi-cants leads to significant adverse healtheffects.60

However, based on existing data, thereis little evidence to support the percep-tion that passing the smoke through wa-ter reduces toxicant exposure.18 Theremay be more reason to believe that thelower temperatures attained by waterpipetobacco (approximately 450oC forwaterpipe vs 900oC degrees for cigarette18)reduce mutagenicity of the smoke com-ponents originating in the tobacco61

though the same is not true for the com-ponents originating in the charcoal. Inany case, discussions of whether the wateror the tobacco temperature reducessmoke toxicant content from some maxi-mal level may be made moot by the factthat, in a single use episode with water inthe waterpipe and a relatively low tobaccotemperature, a waterpipe produces anaverage of 90,000 ml of smoke that, rela-tive to a single cigarette, contains about6 times the CO (Table 2), 46 times the tar(see Table 2), and more than 50 times thequantity of some carcinogenic polycyclicaromatic hydrocarbons,53 as well as heavymetals such as lead and arsenic.18

Exposure to waterpipe-associated toxi-cants is not restricted to users; nearbynonsmokers may also be exposed. Recentstudies show that mainstream smoke froma waterpipe contains high levels of fineparticulate matter,62,63 which can be animportant cardio-respiratory hazard.64,65 Aconsiderable proportion of these particles(eg, PM2.5) are emitted by waterpipe tobaccosmokers to the surrounding air, reachinglevels compared to those associated withcigarette smoking.66 These data justifyinclusion of waterpipe cafés and lounges incurrent clean indoor air policies aimed atprotecting customers and workers of theseestablishments.

What Are the Health Effects ofWaterpipe Tobacco Smoking?Despite the long history of the

waterpipe, the health effects of thismethod of tobacco smoking have not beenas clearly documented as for cigarettes,perhaps due to a lack of adequate re-sources in the world regions wherewaterpipe tobacco smoking traditionallyhas occurred. The available evidence,although scant, suggests that waterpipetobacco smokers, like cigarette smokers,are at risk for nicotine/tobacco depen-dence, cardiovascular disease, and can-cer.

Dependence is thought to representcellular adaptation to chronic drugexposure.eg,67,68 The potential for waterpipeuse to support dependence is based on thefact that waterpipe smoke delivers thedependence-producing drug nicotine.48

Because cellular adaptations are difficultto observe in humans, drug dependenceis characterized behaviorally by repeateddrug self-administration despite knownhealth risks, financial costs, and quitattempts.69 Abstinence effects that aresuppressed by drug administration arealso dependence indicators.70 Althoughmore systematic study is required, atleast some users perceive waterpipe to-bacco smoking to be detrimental to theirhealth and may not be able to quit easily:in one study, 28.4% of waterpipe usersindicated an interest in quitting, withover half of these reporting a past-yearunsuccessful quit attempt.71 Also, in arecent survey of US waterpipe users,12.9% (24/186) said that they were“hooked on a waterpipe.”20 Still, emergingevidence suggests higher quit ratesamong waterpipe users compared to ciga-rette smokers.16,72

One way to assess drug dependence isto terminate drug administration: depen-dence is revealed by abstinence-inducedeffects that are suppressed by subsequentdrug administration.73-75 Importantly, ab-stinent daily waterpipe users report with-drawal symptoms that are suppressed bywaterpipe use.17 Thus, although morestudy is clearly needed, available evi-dence from surveys and clinical labora-tory studies support the idea that tobaccosmoking using a waterpipe supports to-bacco/nicotine dependence.

Waterpipe-induced tobacco/nicotinedependence is likely to share featureswith cigarette smoking (ie, those medi-ated by nicotine), but may also have dis-tinct features attributable to waterpipe-specific characteristics such as setting

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and time of use, accessibility, taste andsmell of flavored waterpipe smoke.13 Tothe extent that empirical study revealsthese distinct features of waterpipe-in-duced dependence, they will need to beaccounted for as smoking cessation in-terventions for waterpipe users are de-veloped.9

More research is also needed to clarifywaterpipe-induced risk of other tobacco-caused diseases, such as cardiovasculardisease and cancer. The existing litera-ture has been reviewed elsewhere3,4 anddemonstrates that waterpipe use may beassociated with coronary heart disease,76

a variety of negative pulmonary out-comes,77,78 and bronchogenic carci-noma.79,80 A recent study demonstratedthat, relative to nonsmokers, both dailywaterpipe tobacco smokers and daily ciga-rette smokers had higher levels ofcarcinoembryonic antigen (CEA), a pro-tein associated with tumor formation.81

In addition, an epidemiological study sug-gests that heavy waterpipe users havesignificantly higher levels of CEA in com-parison to nonsmoking healthy controls.82

Waterpipe tobacco smoking also increasesmicronucleus (MN) frequency, a markerfor early identification of carcinogen-esis.12,83 Waterpipe smoking is also a riskto dental84,85 and fetal health.86-88 Finally,because waterpipe tobacco smoking isoften a social behavior that involves shar-ing the same waterpipe, it may increasethe risk of infectious disease transmis-sion.89 Disposable mouthpieces are avail-able to address this concern, though theiracceptability, actual use, and ultimateeffectiveness are unknown. Importantly,causal links between waterpipe tobaccosmoking and these various health risksare uncertain, due to small sample sizesused in the few existing studies, concur-rent or prior cigarette use among thestudied individuals, and other potentiallyconfounding factors.3,4 As waterpipe to-bacco smoking spreads across the globe,rigorous study and clear communicationregarding its potential effects on healthwill be required.

What Do People Believe AboutWaterpipes?One of the defining features of the

global resurgence in waterpipe use is thewidespread perception that, relative totobacco cigarette smoking, tobacco smok-ing using a waterpipe is likely to be less

lethal due to the presumed but unsub-stantiated “filtering” effects of the water.9

Indeed, several recent US college-basedstudies show that the majority ofwaterpipe tobacco smokers perceive thistobacco use method as being less harmfuland addictive than cigarettes.17,20

Another component of the “reduced”harm/addictiveness perception amongwaterpipe users may be related to thepredominantly intermittent use patternof this tobacco use method.13 However,intermittent waterpipe tobacco smokingdoes not preclude dependence develop-ment – in cigarette smokers, symptomsof nicotine dependence and withdrawalcan appear with intermittent smoking.90,91

Also, the fact that a single episode ofwaterpipe smoking can involve volumesof tobacco smoke that are orders of mag-nitude greater than a single cigarettesuggests that intermittent waterpipe to-bacco smoking may involve substantiallevels of smoke toxicant exposure.

Aside from perceptions regardinghealth risks and addiction, many youngwaterpipe users are attracted to the aro-matic smell of waterpipe smoke and theopportunity it provides for social interac-tion.3,9,92 In particular, the social dimen-sion has emerged in several studies fromcountries in southwest Asia (reviewed inreference 3). In qualitative studies amongArab American adolescents, waterpipeuse has been viewed as being “cool” and away to socialize with friends.92 Socializingis a common theme in the few studiesconducted in the United States: in one,79% of 201 waterpipe tobacco smokerssurveyed reported that they smoked to-bacco in a waterpipe at least in part be-cause it is a good way to socialize withfriends.20 Indeed, a series of recent stud-ies among US college students suggeststhat the majority of waterpipe users viewthe practice as socially acceptable.20,38,39

Perhaps more than with cigarette smok-ing, effective waterpipe prevention inter-ventions will need to deal with the mis-conceptions related to health risks asso-ciated with waterpipe use and addresssome specific features of this tobacco usemethod, including its value and stimulusfor social behavior.

CONCLUSIONS AND IMPLICATIONSWaterpipe tobacco smoking is a grow-

ing health concern globally and especiallyamong young adults in the United States.


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Many waterpipe tobacco smokers perceivethis behavior to be less lethal and addict-ing than cigarettes.20 Converging lines ofevidence, including waterpipe smokeanalysis, user toxicant exposure, andhealth effects research contradict thisperception, though more study is re-quired.83 As more detailed study contin-ues, physicians, policy makers, and to-bacco control advocates can play an im-portant role in addressing perceptionsand minimizing the spread of waterpipetobacco smoking.

One important step that can be takenimmediately is that health care providerscan include waterpipe tobacco smokingwhen evaluating patients, especially ado-lescents and young adults. This inclusioncould come in the form of explicit mentionof waterpipe when implementing stan-dardized assessments93 and clear state-ments that waterpipe tobacco smoke con-tains many of the same toxicants as ciga-rette smoke. On an individual level, theaddition of waterpipe in assessments oftobacco use may help counteract the per-ception that this form of tobacco use isbenign.

To date, waterpipe tobacco smokinghas received little attention in system-atic surveillance, large-scale socialmarketing campaigns, prevention inter-ventions, and other tobacco control ac-tivities. For example, most national sur-veys of tobacco use do not explicitly assesswaterpipe tobacco smoking, makingprevalence estimates difficult. Similarly,clean indoor air legislation in many stateshas been unclear concerning whetherwaterpipe smoking establishments (eg,“hookah cafés”) fall under criteria thatprohibit or limit their operation.94 Also,more must be done to limit minors’ ac-cess to waterpipe products, enforce clearwarning labels on waterpipe tobacco, andensure that common but misleading de-scriptors such as “0% tar” are removedfrom packaging. Until waterpipe tobaccosmoking is included in these and otherinterventions, many young adults arelikely to maintain their belief that it isless lethal than cigarette smoking. In-deed, some may already interpret theabsence of waterpipe tobacco smokingfrom these activities as implied endorse-ment of this perception. By includingwaterpipe tobacco smoking in all levels oftobacco control – from individual provid-ers to large-scale public information cam-

paigns – we may be able to halt andeventually reverse its spread amongAmerican youth.

AcknowledgmentsSources of support include National

Institute on Drug Abuse grantR01DA024876, National Cancer Institutegrants R01CA103827 and R01CA120142,and Fogarty International Center grantR01TW05962.

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