By Carol A. Kemper, MD, FACP

Clinical Associate Professor of Medicine, Stanford University, Division of Infectious Diseases, Santa Clara Valley Medical Center

Dr. Kemper reports no financial relationships relevant to this field of study.

SOURCE: International Society for Infectious Diseases. ProMED-Mail. Tuberculosis — Switzerland: Hookah usage. Dec. 27, 2019.

Smoking a hookah pipe is a centuries-old social custom in some societies. A pipe filled with “shisha,” or flavored tobacco, is passed around in a group, sometimes for hours, often at a hookah cafe. The same mouthpiece is shared, and the device may or may not be cleaned well between uses. Dried tobacco is combined with fruit pulp, molasses, and/or honey — or other flavorings such as coconut, mint, or coffee. This lends a sweet quality to the smoke, which, when drawn through a water bath, gives the impression to many that smoking a hookah is safer than smoking cigarettes.

Apparently, this is not the case. The water bath may diminish the tar from charcoal-burned tobacco, but that bath does not filter many of the cancer-causing chemicals, hydrocarbons, and metals found in today’s tobacco. And it is not just the chemicals: An average hookah contains as much tobacco as 20 filtered cigarettes. The nicotine hit from a hookah is every bit as real — and as addictive — as smoking cigarettes. Further, the temperature of the smoke when heated electronically in newer hookahs, rather than by older charcoal versions, may be cidal to lung cells.

The authors of a recent University of California study found that one good draw on a hookah was similar to smoking one filtered cigarette in terms of hazardous chemicals and metals. Further, the amount of carbon monoxide inhaled during one hookah session was similar to smoking 12 cigarettes.

Another adverse effect from sharing a hookah is the spread of oral and respiratory infections, such as herpes simplex, syphilis, and tuberculosis. While the water bath may filter larger particles, it actually creates ultra-fine particles that can pass directly to the deeper parts of the lungs. Some extra-fine particles (< 0.1 micron) may pass directly through lung tissue into the bloodstream. The authors of this Pro-MED-Mail report identified a 20-year-old man with cavitary tuberculosis (TB). He was a regular hookah smoker, and smoked at least five times per week with friends. The authors theorized regular hookah smoking increased his risk for TB, with close, high-level contact, and spread of microparticles from the mouthpiece. Alternately, frequenting hookah cafés, crowded with people smoking and coughing, also could increase the risk for TB exposure. One wonders if the hot smoke may increase the risk of more severe bacterial or viral lung infection via repeated damage or inflammation to the tissues, similar to vaping.