A hookah is a water pipe used to smoke flavored tobacco. It works by heating tobacco with charcoal, then pulling the smoke down through a water-filled base before it travels up a flexible hose to the smoker’s mouth. The water cools the smoke and filters out some particles, which gives hookah its characteristically smooth draw. Hookahs are typically used in social settings, with sessions lasting around an hour.
Parts of a Hookah
A hookah has four main components. The bowl sits at the top and holds the tobacco and charcoal. The stem is a vertical shaft that connects the bowl to the base and channels smoke downward. The base is a glass or crystal container filled with water. And the hose is a long, flexible tube with a mouthpiece that the smoker inhales through.
Between the bowl and the stem, many hookahs include a diffuser that breaks the smoke into smaller bubbles as it enters the water. This increases the surface area that contacts the water, cooling the smoke further before it reaches the hose.
What’s in Hookah Tobacco
The tobacco smoked in a hookah is called shisha (also spelled “mu’assel,” Arabic for “honeyed”). It’s not the dry, shredded tobacco found in cigarettes. Shisha is made by fermenting tobacco leaves with molasses, vegetable glycerin, and flavoring agents. The result is a moist, sticky mixture that comes in dozens of flavors, from apple and mint to cola and melon. The glycerin is what produces hookah’s thick, voluminous clouds of smoke.
Tobacco-free versions made from sugar cane or herbal blends are marketed as healthier alternatives, often labeled “0% nicotine, 0% tar, 0% tobacco.” These claims are misleading in an important way covered below.
How a Hookah Session Works
Shisha is loosely packed into the bowl, then covered with a perforated sheet of aluminum foil or a heat management device. Lit charcoal briquettes are placed on top. As you inhale through the hose, you create a pressure difference that pulls hot air from the charcoal down through the tobacco, generating smoke. That smoke travels down the stem, bubbles through the water in the base, and rises up through the hose to your mouth.
A typical session uses about 10 grams of shisha and lasts roughly an hour, during which a smoker may take 100 to 200 puffs. That’s a key distinction from cigarettes: a single hookah session involves inhaling about 90,000 milliliters of smoke, compared to 500 to 600 milliliters from one cigarette. That’s 100 to 200 times the volume of smoke.
How Hookah Compares to Cigarettes
The water filtration and sweet flavors create a perception that hookah is safer than cigarettes. It isn’t. According to the CDC, a single hookah session exposes the smoker to nearly 9 times more carbon monoxide and 1.7 times more nicotine than a single cigarette. For every 100 puffs, a smoker takes in about 2.25 milligrams of nicotine and 242 milligrams of tar, along with higher amounts of arsenic, chromium, and lead compared to a cigarette.
Even occasional use has measurable effects. A single hookah session produces nicotine byproducts in urine equivalent to smoking two cigarettes in one day, even in people who don’t smoke hookah regularly. The nicotine content is more than enough to create dependence over time.
Toxins and Heavy Metals in the Smoke
Much of what makes hookah smoke harmful doesn’t come from the tobacco itself. It comes from the charcoal. Burning charcoal generates large quantities of carbon monoxide, cancer-linked compounds called polycyclic aromatic hydrocarbons (PAHs), and formaldehyde. The sweeteners in shisha also break down under heat into volatile aldehydes, another class of harmful chemicals.
This is why tobacco-free shisha isn’t meaningfully safer. In controlled testing, herbal shisha produced virtually identical levels of carbon monoxide, carcinogenic compounds, and formaldehyde as regular tobacco shisha. The only significant difference was nicotine: the herbal product contained almost none. But every other toxin that contributes to cancer, cardiovascular disease, and lung disease was present in comparable amounts. If the charcoal is burning and sweeteners are present, the harmful chemistry is largely the same regardless of what’s in the bowl.
Heavy metal exposure is another concern. Analysis of hookah tobacco and wastewater has found lead, cobalt, copper, antimony, and aluminum at levels that pose health risks. Aluminum, in particular, showed up at concerning levels in both best-case and worst-case exposure scenarios.
Secondhand Smoke Indoors
Hookah produces significant indoor air pollution. In a study comparing homes where hookah was smoked, homes where cigarettes were smoked, and nonsmoking homes, fine particulate matter (PM2.5) in hookah smoking rooms averaged about 429 micrograms per cubic meter. That was more than double the level in cigarette smoking rooms (201) and nearly five times higher than nonsmoking homes (93). Carbon monoxide levels in rooms adjacent to where hookah was smoked were 2.5 to 4 times higher than levels found anywhere in cigarette-smoking homes.
If you’re in the same room or even an adjacent room while someone smokes hookah, your exposure to fine particles and carbon monoxide is substantial.
Infection Risks From Sharing
Hookah is a social activity, and sharing the hose is common. This creates a direct route for transmitting infections. Studies sampling mouthpieces at hookah bars have found both common and antibiotic-resistant bacteria, including Staphylococcus aureus, E. coli, Pseudomonas, and Streptococcus. Tuberculosis-causing bacteria, fungal spores, and Helicobacter pylori (which causes stomach ulcers) have also been isolated from water pipes.
The hepatitis C virus has been linked to shared mouthpieces as well, and researchers flagged hookah sharing as a potential transmission route for respiratory viruses including MERS. Disposable plastic tips reduce some of this risk, but they don’t eliminate contact with the hose itself or the shared air in the pipe’s chamber.
Origins of the Hookah
The hookah dates to at least the mid-1500s. Its exact origin is debated: Persian poetry references a water pipe as early as 1535, and an Iranian physician named Abul-Fath Gilani is credited with introducing the device in India during the Mughal period in the 1560s. From the Indian subcontinent, the hookah spread to Persia, where its design was refined into roughly the form used today, and then throughout the Ottoman Empire. It has been a fixture of social life across the Middle East, South Asia, and North Africa for centuries, and hookah lounges have become increasingly popular in Europe and North America over the past two decades.