Facts About Hookah

What Is a Hookah?

• Hookahs are waterpipes that are used to smoke specially made tobacco mixtures that come in a wide variety of flavors.
• They usually work by passing charcoal-heated air through the tobacco mixture and ultimately through a water-filled chamber.
• A user then inhales the smoke through a tube and mouthpiece.

Who Uses Hookahs?

• Data from a 2017 study showed that the prevalence of pipes or hookahs was higher among white individuals, and there was a higher prevalence within the Midwest region of the United States.²
• The same 2017 study showed that hookah use was more prevalent in urban areas than in rural areas.²
• A 2022 study showed that nearly 1 in every 36 (36%) 12th grade high school students used a hookah to smoke tobacco in the past 12 months.¹
• The 2023 National Youth Tobacco Survey found that 1% of every middle school student smoked hookah in the past 12 months.³
• While recent studies have shown a decrease in use of traditional hookah smoking, from 7.8% in 2018 to 2.7% in 2023, the use of electronic hookahs (e-hookahs) and other electronic nicotine delivery systems are now available.⁴ None of these products are a safe alternative to cigarette smoking.

Health Effects of Hookah

• Hookah users often perceive it to be less harmful than smoking cigarettes, but studies show that the smoke contains many of the same toxic components found in cigarette smoke, such as nicotine, tar and heavy metals.¹
• Although the smoke from a hookah passes through water, it does not filter out the smoke or other toxic agents.¹
• Hookah smoke users can be exposed to 9 times more carbon monoxide and 1.7 times more nicotine then from a single cigarette¹
• Smoking increases the likelihood of adverse health effects including reproductive health, cardiovascular health, chronic obstructive pulmonary disease and cancer.²
• Sweetners and flavorings in hookahs may increase the risk of smoke-related toxins which can lead to negative health effects on the lungs.⁵

What Are Some of the Public Policies that Apply to Hookah?

• In 2016, FDA finalized a rule extending their regulatory authority to cover all tobacco products, including hookah tobacco. However, FDA delayed its oversight of the hookah labeling, advertising, promotion, sale, and distribution of hookah tobacco until 2021, so there is no current oversight of these products.
• In states or localities with smokefree laws, hookah bars often receive an exemption:
  • A 2015 study found exemptions for hookah establishments in smokefree laws in 24 states, and loopholes that exempt establishments that receive a set percentage of sales from tobacco products in another 14 states.⁶
  • A review of smokefree laws in the 100 largest U.S. cities found that 69 of the 73 cities that prohibit cigarette smoking in bars had exemptions for hookah use.⁷
• Removing loopholes for hookah establishments in smokefree laws can reduce exposure to secondhand smoke and help keep hookah out of the hands of kids.
• States and localities where allowed have clear authority to restrict the sale of flavored tobacco products (or any tobacco product) to reduce tobacco use and its harms to its citizens. Several localities have passed restrictions on sales of flavored tobacco products that affect hookah tobacco, including San Francisco and Minneapolis.
• The tobacco used for hookah is often taxed at a lower rate than cigarettes in states and at the federal level. Higher taxes, which increase the price of hookah are an effective way to reduce youth tobacco use. When available at lower prices it provides cigarette smokers with an alternative, lower-priced tobacco product. It also incentivizes smokers to switch products rather than quit.