This document analyzes whether hookah smoking is safer than cigarette smoking by comparing their chemical yields, risks of secondhand smoke, correlation to diseases, and societal perceptions. It finds that one hookah smoking session yields significantly more nicotine, carbon monoxide, and smoke volume than smoking multiple cigarettes. Secondhand hookah smoke exposes others to smoke and harmful heating byproducts. Areas where hookah is popular, like Kashmir, show high lung cancer rates among hookah smokers comparable to cigarette smokers. However, society generally perceives hookah as less harmful despite the evidence that it can be as or more dangerous than cigarette smoking.

1. Is Hookah Safer than Cigarette Smoking?
Public Health Literature
November 27, 2015
By: Ramandeep Kaur
IS HOOKAH SAFER
THAN CIGARETTE
SMOKING?
Ramandeep Kaur
Public Health Literature

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Table of Contents
Topic Page
I. Abstract…………………………………………………………………………….4
II. Introduction………………………………………………………………………...4
III. Methods………………………………………………………………………….....5
IV. Findings………………………………………………………………………….....7
a. Perception of Society on Hookah versus Cigarettes…………………………...7
b. Chemical Yield of Hookah versus chemical yield of Cigarettes……………....7
c. Second Hand Smoking ………………………………………………………..7
d. Aging of Smoke between Hookah and Cigarettes……………………………..8
e. Correlation Between Hookah Smoking and Diseases…………………………8
f. Regulations Involved with Hookah Smoking…………………………………9
V. Discussion………………………………………………………………………....11
VI. Conclusion…………………………………………………………………………12

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Table of Figures
Topic Page
I. Figure 1…………………………………………………………………..10
a. Perception of Society on Hookah Smoking
II. Figure 2…………………………………………………………………..10
a. The Comparison of Water Pipe to Cigarettes
III. Figure 3…………………………………………………………………..10
a. Chemical Yield of Hookah Smoking versus Cigarette Smoking
IV. Figure 4…………………………………………………………………..11
a. Morbidity Rate of Diseases Due to Cigarettes
V. Figure 5…………………………………………………………………..11
a. The Prevalence of Lung Cancer in Smokers and Nonsmokers in
Kashmir

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Abstract
Although there is advanced knowledge about smoking around the world, there still is not
enough studies and awareness of certain methods of smoking, such as hookah. Within the past
decade, hookah is becoming a popular aspect of the social culture. Over the past few years, it has
become common knowledge that excessive smoking causes lung cancer, so why is hookah so
popular? Unfortunately, the society does not realize how harmful hookah really is to the health
and wellbeing. This research will examine the degree to how harmful hookah is by comparing it
to cigarette smoking. By comparing the side effects of something recent to something that
everyone knows about, it will give the society a perspective and will spread awareness on the
issue at hand.
Introduction
Although this issue of hookah has not completely been recognized, hookah is one of the
number one causes for various diseases and social problems. If hookah is banned, this would
benefit the society’s health significantly. The society is aware of the fact that cigarette smoking
can cause up to 87% deaths worldwide; along with lung cancer, it can also cause cancers of
larynx, oral cavity, pharynx, esophagus and bladder. However, the society does not have much
knowledge about the effects of hookah. Hookah originated in India and spread to the Middle
Eastern culture. Since the past decade, it has been spreading in Europe and the US (Aljarrah,
Ababneh and Al-Delaimy). Hookah lounges are growing in the population exponentially. Also,
hookah lounges provide fancy drink options with hookah to make it a delightful experience. The
lounges also incorporates different flavors for hookah. These tactics are enticing the society,
especially the young generation, to make hookah lounge their social hang out spot. This is very

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concerning because the young generation is not aware of effects of hookah, especially since there
are not enough programs and studies that advocate the harmfulness of hookah. Programs, such as
D.A.R.E., discourage the use of alcohol, drugs, and cigarette smoking but do not discourage the
use of hookah smoking.
An analysis of the perception of the society on hookah smoking was done. According to
figure 1, 62.6% of the male population thinks that hookah is less harmful than cigarettes while
52.5% of the female population think that hookah is less harmful than cigarettes. This data shows
that most people think that cigarette smoking is worse than hookah smoking. The population
does not know about the risks associated with hookah smoking (Aljarrah, Ababneh and Al-
Delaimy). Also, looking at the fact that hookah is becoming a popular aspect of the culture
allows people to assume that hookah must not be bad. People also think that hookah is safe
because it has less nicotine and less toxic due to the filtering mechanism (Morris, Fiala and
Pawlak). However, that is not true. As explained further in this research, there is tar, nicotine and
various other chemicals in the hookah, which are not filtered. Therefore, this research highlights
the facts which explain why hookah smoking is worse than cigarette smoking.
Methods
In order to understand the thinking of the society on the issue of hookah, this research does
an analysis of the perception of the society on what they think is worse: hookah or cigarettes.
Providing this information will explain the reasoning of why this research is being conducted in
the first place. In order to fully understand the harmful effects of hookah smoking, this research
first examined the comparison between hookah smoking and cigarette smoking. This step
provides information on the types of chemicals inhaled, the amount of chemicals inhaled, and
which type of smoking has a greater side effect. It also explains how many packs of cigarettes

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need to be smoked in order to yield the same amount of chemicals that one session of hookah
smoking yields. In addition to that, the effects were seen of second hand hookah smoking in
lounges. There was a comparison done between second hand smoking of cigarettes versus
second hand smoking of hookah. This analysis demonstrates that there are different mechanisms
for different type of smoking, making one type of smoking worse than the other. Hence, this
provides the degree to which hookah smoking can be harmful to the health and wellbeing.
After analyzing the effects of cigarette smoking versus hookah smoking, this research did
an analysis of the correlation of hookah smoking to various diseases. This provided information
of how badly hookah affects the body compared to how badly cigarettes affect the body. If
smoking one cigarette a day (500 mL) can cause lung cancer, one can imagine what a session of
hookah (90,000 mL) per day can do (Martinasek, McDermott and Martini). Therefore,
comparing two methods of smoking gives the society a perspective of how detrimental hookah
smoking really is.
To support the statement that hookah is worse than the society thinks it is, this research
included the study of areas in which hookah is part of their culture, such as Kashmir. This
involved an analysis of how many smokers and nonsmokers are in Kashmir. Amongst the
smokers, there was a count of how many were hookah smokers, cigarette smokers or both. Then,
it shows the prevalence of lung cancer amongst different type of smokers and nonsmokers. By
examining the effects of hookah in the society and acquiring an understanding of the current
issue, the future progression of this issue can be made. Therefore, this research will show the up
rise of this new culture that involves hookah and the effects of it in the society. It will also show
the degree to which hookah is harmful. This insight helps the society that is involved in hookah
smoking to understand the scale to which they are really affecting their body.

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Findings
Figure 2 shows the comparison of chemical yield between hookah smoking and
cigarette smoking. According to the figure, hookah smoking yields 60 ng/ mL of nicotine while
cigarette smoking yields approximately 18 ng/ mL of nicotine (WHO.int). Looking at further
chemical yields, the figure also shows that hookah smoking yields 15 ppm of carbon monoxide
(CO) while cigarette smoking yields 5 ppm of CO (WHO.int). To put it in perspective, figure 3
shows how many packs of cigarettes a person needs to smoke in order to equal the amount of
chemicals hookah yields in one smoking session (1 gm), which lasts an hour on average. A
person needs to smoke eleven packs of cigarette to equal the amount of carbon monoxide yield
from one session of hookah smoking (WHO.int). Furthermore, a person needs to smoke four
packs of cigarettes to equal the amount of nicotine yield from one session of hookah smoking
(WHO.int). All these risks are also associated with the level of exposure to smoke itself. One
hookah smoking session involves 200 puffs while one cigarette involves 20 puffs (CDC).
Anyone can assume and/ or agree with that fact because hookah emits a cloud of smoke, unlike
cigarettes. The amount of smoke inhaled during a single hookah session is 90,000 mL while the
amount of smoke inhaled by a single cigarette is 500-600 mL (CDC).
In addition to the comparison of chemical yield between hookah and cigarettes, the
second hand smoking with hookah versus cigarettes is a significant factor in determining which
method of smoking is worse. WHO offers a universal definition for second hand smoking:
“Second-hand tobacco smoke (SHS) refers to the smoke from burning tobacco products,
generated by people smoking them.” The specificity of the universal definition is not accurate
enough because it does not include the mechanism of hookah smoking. The reasoning is that

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hookah smoking is formed by heating using mechanisms like charcoal (Chaouachi). The organic
compounds produced at high temperature are condensed and retained in the water in hookah
bowl. As mentioned earlier, a significant amount of carbon monoxide is formed as well from
heating mechanism which is very toxic due to its competitive binding with hemoglobin, a protein
molecule that is supposed to carry oxygen (Khan, Akhter, and Malik). Therefore, when a person
is second hand smoking hookah, he or she is inhaling the smoking product in the hookah bowl,
along with the heating product (e.g. charcoal, carbon monoxide). This is more dangerous than
second hand smoking of cigarette because a person would not be inhaling any heating product
(Chaouachi).
Furthermore, smoke exhibits aging which contributes to which type of smoking is
worse. For example, in cigarette smoking, the decrease in NO from fresh smoke is accompanied
by increase in NO2 (Chaouachi). The NO2 reaches a maximum and beings to decrease after a
minute (Chaouachi). Then, the CH3OH is stable but then begins to decrease alongside the NO2
(Chaouachi). This causes a reaction, which makes the fresh tobacco smoke to not be fresh
anymore—it is aging (Chaouachi). Now this example can be compared to the magnitude of
harmfulness of hookah smoking. Hookah smoke covers twenty five times the distance of
cigarette smoke (Chaouachi). Therefore, the aging of hookah has a bigger effect on the health of
the community than the aging of cigarettes.
Now that a comparison has been done between hookah smoking and cigarette smoking,
let’s have a glance on the correlation between hookah smoking and diseases. Figure 4 shows that
cigarette smoking causes over 20,000 deaths per year due to diseases such as acute respiratory
infection, otitis, asthma, ischaemic heart disease and lung cancer (CDC). If cigarette smoking
can cause that many deaths, one can imagine how many deaths hookah smoking can cause.

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Furthermore, a study was conducted in Kashmir to show the prevalence of lung cancer due to
hookah smoking, cigarette smoking or both (Koul et al.). Figure 5 shows the results of the study.
The figure shows that 48% of exclusive hookah smokers have lung cancer; 18% of exclusive
cigarette smokers have lung cancer; 11% of combines smokers have lung cancer and 23% of
nonsmokers have lung cancer (Koul et al.). The percentage of nonsmokers who have lung cancer
is significantly high because there was so much hookah smoke in Kashmir that the chemicals
were being absorbed by the water that was running in the community’s household (Koul et al.).
Unfortunately, there are not enough public health initiatives that discourage the use of
smoking hookah. Policies related to smoking includes efforts such as tax, restriction on selling
product to minors, regulation of advertising, and control of the content of the product. Although
there is less mention of water pipe smoking (hookah), the rules by WHO apply to all tobacco
products, including hookah (Martinasek,McDermottandMartini). After a decade of increasing data
of the increased prevalence of diseases from hookah, WHO declared an advisory note that states:
“using a water pipe to smoke tobacco poses a serious potential health hazard to smokers and
others exposed to the smoke emitted” (Martinasek,McDermottand Martini). Despite of the
cautionary note by WHO, water pipe smoking is still not regulated. The product coming from
places like Dubai, Palestine, Jordan, Bahrain, etc., have a sign saying “no tar” (Martinasek,
McDermott and Martini). However, that is not accurate. The tar is a combustion product for
hookah smoking so hookah is not in compliance with rules (Martinasek,McDermottandMartini).
Hence, hookah continues to be very popular in U.S. and Europe and there are no set regulations
against it.

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Figure 2. The comparison
of waterpipe tocigarette
smoking
Figure 3. Chemical Yield
of Hookah Smoking vs.
Cigarette Smoking
Figure 1. Perception of
Society on Hookah
Smoking

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Discussion:
Hookah Smoking has become so popular over the past decade because the society is
unaware of the harmful effects of hookah. In fact, many nonsmokers have smoked hookah
thinking that is harmless and does not contain any significant chemicals that can deteriorate the
body (Nakkash,Khalil andAfifi). Thisresearchshowsthe degreetowhichhookahaffectsthe body
Figure 5. The prevalence of
lungcancer insmokersand
nonsmokers in Kashmir
Figure 4. Morbidity Rate of
Various Diseases Due to
Cigarette Smoking

12. Kaur 11
negatively. The comparison of cigarettes and hookah was done and the analysis shows that
hookah is much worse than cigarettes. In the past decade, WHO has made an effort to regulate
hookah smoking. However, there is still plenty of work to be done.
Conclusion
Increasing hookah lounges in parts of the world is becoming a prevalent issue that needs
to be resolved. It is becoming such a popular aspect of the culture that many public health
initiatives decided to focus on the epidemic to see if it poses any possible threat to the health of
the community. The public health initiatives does encourage tactics such as health warnings,
counseling, providing statistics of smoking causing various cancer, etc. However, the regulation
does not cover the complete scope of threat. Therefore, further regulations need to be
implemented in order to guarantee the safety of the community.
Public health initiatives and programs such as the CDC or WHO need to focus on
changing classification and/ or characterization of the regulation so that the harmful effects of
hookah are completely discouraged. It may not be possible to ban hookah entirely but one
possibility that public health analysts should work on is decreasing the number of hookah
lounges in different parts of the world. Furthermore, public health analysts should think about
decreasing the selling of hookah products. This can significantly decrease the popularity of
hookah smoking in the recent culture.

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PredictorsAndCharacteristicsAmongCurrentHookahUsers'. Tob.Induced Dis. 5.1 (2009): 16.
Web.4 Dec.2015.
Barnett, Tracey E., et al. "Evidence of emerging hookah use among university students: a cross-sectional
comparison between hookah and cigarette use."BMC public health 13.1 (2013): 302.
Chaouachi,Kamal.'Hookah(Shisha,Narghile)SmokingAndEnvironmental TobaccoSmoke (ETS).A
Critical ReviewOf The RelevantLiterature AndThe PublicHealthConsequences'. International
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Cobb,C. O. etal.'Indoor AirQualityInVirginiaWaterpipeCafes'. Tobacco Control22.5 (2012): 338-343.
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Koul,ParvaizA etal.'Lung CancerIn The KashmirValley'. Lung India 27.3 (2010): 131. Web.
Martinasek,Mary P.,RobertJ. McDermott, andLeilaMartini.'Waterpipe (Hookah) TobaccoSmoking
AmongYouth'. CurrentProblemsin Pediatric and AdolescentHealth Care 41.2 (2011): 34-57.
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Morris, Daniel S.,StevenC.Fiala,andRebeccaPawlak.'OpportunitiesForPolicyInterventionsToReduce
Youth HookahSmokingInThe UnitedStates'. Preventing ChronicDisease9 (2012): n.pag. Web.
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Nakkash,RimaT, JoannaKhalil,andRemaA Afifi.'The Rise InNarghile (Shisha,Hookah) Waterpipe
Tobacco Smoking:A Qualitative StudyOf PerceptionsOf SmokersAndNonSmokers'. BMCPublic
Health 11.1 (2011): 315. Web.7 Dec. 2015.

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Sajid, Khan Mohammad, Mahfooz Akhter, and C. Q. Malik. "Carbon monoxide fractions in
cigarette and hookah (hubblebubble) smoke." Journal of the Pakistani Medical
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