Editing Hookah (section)

==Health effects==
{{Further|Health effects of tobacco|Mu‘assel#Health effects}}

=== Exposure to toxic chemicals ===
Tobacco smoke contains toxic chemicals, including carcinogens (chemicals that cause cancer).<ref name="Akl10">{{cite journal|last1=Akl|first1=EA|last2=Gaddam|first2=S|last3=Gunukula|first3=SK|last4=Honeine|first4=R|last5=Jaoude|first5=PA|last6=Irani|first6=J|date=2010|title=The effects of waterpipe tobacco smoking on health outcomes: a systematic review|journal=International Journal of Epidemiology|volume=39|issue=3|pages=834–57|doi=10.1093/ije/dyq002|pmid=20207606|doi-access=free}}<!--|access-date=13 June 2015--></ref> Water does not filter out many of these chemicals.<ref name="Akl10" /> The toxic chemicals come from the burning of the charcoal, tobacco, and flavorings. These chemicals can lead to cancer, heart disease, lung disease, and other health problems.<ref name="Shihadeh15">{{cite journal|last1=Shihadeh|first1=A|last2=Schubert|first2=J|last3=Klaiany|first3=J|last4=El Sabban|first4=M|last5=Luch|first5=A|last6=Saliba|first6=NA|date=2015|title=Toxicant content, physical properties and biological activity of waterpipe tobacco smoke and its tobacco-free alternatives|journal=Tobacco Control|volume=24|issue=Supplement 1|pages=i22–i30|doi=10.1136/tobaccocontrol-2014-051907|pmc=4345918|pmid=25666550}}<!--|access-date=13 June 2015--></ref><ref>{{cite journal|last1=Grillo|first1=R|last2=Khemiss|first2=M|last3=Slusarenko da Silva|first3=Y|date=2023|title=Cytotoxic and genotoxic effects of waterpipe on oral health status: A systematic review and meta-analysis|journal=Sultan Qaboos University Medical Journal|volume=23|issue=1|pages=5–12|doi=10.18295/SQUMJ.6.2022.043|pmid=36865434|pmc=9974039}}</ref> 
The toxic chemicals include tobacco-specific nitrosamines, polycyclic aromatic hydrocarbons (PAHs; e.g., benzo[a]pyrene and anthracene), volatile aldehydes (e.g. [[formaldehyde]], acetaldehyde, [[acrolein]]), benzene, nitric oxide, heavy metals (arsenic, chromium, lead), and carbon monoxide (CO).<ref name="Shihadeh15" /> Hookah smoking also increases the amount of carbon monoxide (CO) in a person's body to eight times their normal level.<ref name="Martinasek14">{{cite journal|last1=Martinasek|first1=MP|last2=Ward|first2=KD|last3=Calvanese|first3=AV|date=2014|title=Change in carbon monoxide exposure among waterpipe bar patrons|journal=Nicotine & Tobacco Research|volume=16|issue=7|pages=1014–9|doi=10.1093/ntr/ntu041|pmid=24642592}}<!--|access-date=13 June 2015--></ref> Compared to smoking one cigarette, a single hookah session exposes users to more carbon monoxide and PAHs, similar levels of nicotine, and lower levels of tobacco-specific nitrosamines.<ref name="WHO15" /><ref name="Shihadeh15" /> By inhaling these chemicals, hookah smokers are at increased risk of many of the same health problems as cigarette smokers.<ref name="ElZaatari15" /><ref name="Akl10" /> During an average hookah smoking session, smokers inhale 100–200 times more smoke than from smoking a single cigarette.<ref>{{Cite web |last=CDCTobaccoFree |date=2023-10-20 |title=Hookahs |url=https://www.cdc.gov/tobacco/data_statistics/fact_sheets/tobacco_industry/hookahs/index.htm |access-date=2024-01-30 |website=Centers for Disease Control and Prevention|archive-date=1 June 2024 |archive-url=https://web.archive.org/web/20240601132951/https://www.cdc.gov/tobacco/data_statistics/fact_sheets/tobacco_industry/hookahs/index.htm |url-status=live }}</ref>

=== Exposure to pathogens that cause infectious diseases ===
When people share a hookah, there is a risk of spreading infectious diseases such as [[oral herpes]], [[tuberculosis]], [[hepatitis]], [[influenza]], and ''[[Helicobacter pylori|H. pylori]]''.<ref name="ALAgrowingThreat">{{cite web |publisher=American Lung Association |url=http://www.lung.org/assets/documents/tobacco/hookah-policy-brief-updated.pdf |title=Hookah Smoking – A Growing Threat to Public Health |access-date=27 June 2018 |archive-date=18 September 2017 |archive-url=https://web.archive.org/web/20170918162317/http://www.lung.org/assets/documents/tobacco/hookah-policy-brief-updated.pdf |url-status=dead }}</ref> Using personal disposable mouthpieces may reduce this risk, but does not eliminate it.<ref>{{cite web |title=Waterpipe and Hookah Smoking – A Dangerous New Trend |date=30 October 2015 |publisher=Simcoe Muskoka District Health Unit |url=http://www.simcoemuskokahealth.org/Topics/Tobacco/TobaccoUsePrevention/HookahsAndWaterpipes.aspx |access-date=13 June 2015 |archive-url=https://web.archive.org/web/20160625062356/http://www.simcoemuskokahealth.org/Topics/Tobacco/TobaccoUsePrevention/HookahsAndWaterpipes.aspx |archive-date=25 June 2016 |url-status=dead }}</ref>

=== Addiction to and dependence on hookah ===
Hookah smokers inhale [[nicotine]], which is an addictive chemical. A typical hookah smoking session delivers 1.7 times the nicotine dose of one cigarette<ref name="Eissenberg09">{{cite journal|last1=Eissenberg|first1=T|last2=Shihadeh|first2=A|date=December 2009|title=Waterpipe tobacco and cigarette smoking: direct comparison of toxicant exposure|journal=American Journal of Preventive Medicine|volume=37|issue=6|pages=518–23|doi=10.1016/j.amepre.2009.07.014|pmc=2805076|pmid=19944918}}<!--|access-date=13 June 2015--></ref> and the nicotine absorption rate in daily waterpipe users is equivalent to smoking 10 cigarettes per day.<ref name="Neergaard07">{{cite journal|last1=Neergaard|first1=J|last2=Singh|first2=P|last3=Job|first3=J|last4=Montgomery|first4=S|date=October 2007|title=Waterpipe smoking and nicotine exposure: a review of the current evidence|journal=Nicotine & Tobacco Research|volume=9|issue=10|pages=987–94|doi=10.1080/14622200701591591|pmc=3276363|pmid=17943617}}<!--|access-date=13 June 2015--></ref> Many hookah smokers, especially frequent users, have urges to smoke and show other [[Drug withdrawal|withdrawal]] symptoms after not smoking for some time, and it can be difficult to quit.<ref name="Aboaziza15">{{cite journal|last1=Aboaziza|first1=E|last2=Eissenberg|first2=T|date=March 2015|title=Waterpipe tobacco smoking: what is the evidence that it supports nicotine/tobacco dependence?|journal=Tobacco Control|volume=24|issue=Suppl 1|pages=i44–i53|doi=10.1136/tobaccocontrol-2014-051910|pmc=4345797|pmid=25492935}}<!--|access-date=13 June 2015--></ref><ref name="Asfar14">{{cite journal|last1=Asfar|first1=T|last2=Al Ali|first2=R|last3=Rastam|first3=S|last4=Maziak|first4=W|last5=Ward|first5=KD|date=June 2014|title=Behavioral cessation treatment of waterpipe smoking: The first pilot randomized controlled trial|journal=Addictive Behaviors|volume=39|issue=6|pages=1066–74|doi=10.1016/j.addbeh.2014.02.012|pmc=4141480|pmid=24629480}}<!--|access-date=13 June 2015--></ref><ref name="Rastam2011">{{cite journal|last1=Rastam|first1=S|last2=Eissenberg|first2=T|last3=Ibrahim|first3=I|last4=Ward|first4=KD|last5=Khalil|first5=R|last6=Maziak|first6=W|date=May 2011|title=Comparative analysis of waterpipe and cigarette suppression of abstinence and craving symptoms|journal=Addictive Behaviors|volume=36|issue=5|pages=555–9|doi=10.1016/j.addbeh.2011.01.021|pmc=3061840|pmid=21316156}}<!--|access-date=13 June 2015--></ref><ref name="Ward05">{{cite journal|last1=Ward|first1=KD|last2=Hammal|first2=F|last3=VanderWeg|first3=MW|last4=Eissenberg|first4=T|last5=Asfar|first5=T|last6=Rastam|first6=S|last7=Maziak|first7=W|date=February 2005|title=Are waterpipe users interested in quitting?|journal=Nicotine & Tobacco Research|volume=7|issue=1|pages=149–56|citeseerx=10.1.1.625.4651|doi=10.1080/14622200412331328402|pmid=15804687}}<!--|access-date=13 June 2015--></ref> People who become addicted to hookah may be more likely to smoke alone.<ref name="Maziak05">{{cite journal|last1=Maziak|first1=W|last2=Eissenberg|first2=T|last3=Ward|first3=KD|date=January 2005|title=Patterns of waterpipe use and dependence: implications for intervention development|journal=Pharmacology Biochemistry and Behavior|volume=80|issue=1|pages=173–9|doi=10.1016/j.pbb.2004.10.026|pmid=15652393|s2cid=22556876}}<!--|access-date=13 June 2015--></ref> Hookah smokers who are addicted may find it easier to quit if they have help from a quit-smoking counseling program.<ref name=Asfar14 /><ref name="Dogar14">{{cite journal|last1=Dogar|first1=O|last2=Jawad|first2=M|last3=Shah|first3=SK|last4=Newell|first4=JN|last5=Kanaan|first5=M|last6=Khan|first6=MA|last7=Siddiqi|first7=K|date=June 2014|title=Effect of cessation interventions on hookah smoking: post-hoc analysis of a cluster-randomized controlled trial|journal=Nicotine & Tobacco Research|volume=16|issue=6|pages=682–8|doi=10.1093/ntr/ntt211|pmid=24376277}}<!--|access-date=13 June 2015--></ref><ref>{{Cite journal|last1=Maziak|first1=Wasim|last2=Jawad|first2=Mohammed|last3=Jawad|first3=Sena|last4=Ward|first4=Kenneth D.|last5=Eissenberg|first5=Thomas|last6=Asfar|first6=Taghrid|date=2015-07-31|title=Interventions for waterpipe smoking cessation|journal=The Cochrane Database of Systematic Reviews|volume=2015 |issue=7|pages=CD005549|doi=10.1002/14651858.CD005549.pub3|issn=1469-493X|pmc=4838024|pmid=26228266}}</ref>

=== Short-term health effects ===
Carbon monoxide (CO) in hookah smoke binds to hemoglobin in the blood to form [[carboxyhemoglobin]], which reduces the amount of oxygen that can be transported to organs including the brain. There are several case reports in the medical literature of hookah smokers needing treatment in hospital emergency rooms for symptoms of CO poisoning including [[headache]], [[nausea]], [[lethargy]], and [[fainting]].<ref name="Cavus10">{{cite journal |last1=Cavus |first1=UY |last2=Rehber |first2=ZH |last3=Ozeke |first3=O |last4=Ilkay |first4=E |title=Carbon monoxide poisoning associated with narghile use |journal=Emergency Medicine Journal |date=2010 |volume=27 |issue=5 |page=406 |doi=10.1136/emj.2009.077214 |pmid=20442182 |s2cid=2332261 }}<!--|access-date=13 June 2015--></ref><ref name="LaFauci12">{{cite journal |last1=La Fauci |first1=G |last2=Weiser |first2=G |last3=Steiner |first3=IP |last4=Shavit |first4=I |title=Carbon monoxide poisoning in narghile (water pipe) tobacco smokers |journal=Canadian Journal of Emergency Medicine |date=2012 |volume=14 |issue=1 |pages=57–59 |pmid=22417961 |doi=10.2310/8000.2011.110431 |doi-access=free }}<!--|access-date=13 June 2015--></ref><ref name="Lim09">{{cite journal |last1=Lim |first1=BL |last2=Lim |first2=GH |last3=Seow |first3=E |title=Case of carbon monoxide poisoning after smoking shisha |journal=International Journal of Emergency Medicine |date=2009 |volume=2 |issue=2 |pages=121–122 |doi=10.1007/s12245-009-0097-8|pmid=20157455 |pmc=2700232 }}<!--|access-date=13 June 2015 --></ref><ref name="Turkmen11">{{cite journal |last1=Türkmen |first1=S |last2=Eryigit |first2=U |last3=Sahin |first3=A |last4=Yeniocak |first4=S |last5=Turedi |first5=S |title=Carbon monoxide poisoning associated with water pipe smoking |journal=Clinical Toxicology |date=2011 |volume=49 |issue=7 |pages=697–698 |doi=10.3109/15563650.2011.598160 |pmid=21819288|s2cid=43906064 }}</ref> This is sometimes called "hookah sickness".<ref name="Pearl15">{{cite news |last1=Pearl |first1=Mike |title=Is hookah sickness just carbon monoxide poisoning |url=http://influxnews.com/is-hookah-sickness-just-carbon-monoxide-poisoning/ |access-date=13 June 2015 |url-status=dead |archive-url=https://web.archive.org/web/20150615061103/http://influxnews.com/is-hookah-sickness-just-carbon-monoxide-poisoning/ |archive-date=15 June 2015}}</ref> Hookah smoking can damage the [[cardiovascular system]] in several ways.<ref name="WHO15" /><ref name="ElZaatari15" /> Its use elevates [[heart rate]] and [[blood pressure]].<ref name="Alomari14">{{cite journal |last1=Alomari |first1=MA |last2=Khabour |first2=OF |last3=Alzoubi |first3=KH |last4=Shqair |first4=DM |last5=Eissenberg |first5=T |title=Central and peripheral cardiovascular changes immediately after waterpipe smoking |date=2014 |volume=26 |issue=10 |pages=579–587 |doi=10.3109/08958378.2014.936572 |pmid=25144473 |journal=Inhal Toxicol |bibcode=2014InhTx..26..579A |s2cid=30687980 |url=https://figshare.com/articles/dataset/Central_and_peripheral_cardiovascular_changes_immediately_after_waterpipe_smoking/1577598 |access-date=2 December 2021 |archive-date=26 March 2024 |archive-url=https://web.archive.org/web/20240326080125/https://figshare.com/articles/dataset/Central_and_peripheral_cardiovascular_changes_immediately_after_waterpipe_smoking/1577598 |url-status=live }}<!--|access-date=13 June 2015 --></ref> It also impairs [[baroreflex]] control (which helps to control blood pressure)<ref name="AlKubati06">{{cite journal |last1=Al-Kubati |first1=M |last2=Al-Kubati |first2=AS |last3=al'Absi |first3=M |last4=Fiser |first4=B. |title=The short-term effect of water-pipe smoking on the baroreflex control of heart rate in normotensives |journal=Autonomic Neuroscience |date=2006 |volume=126–127 |pages=146–9 |pmid=16716761 |doi=10.1016/j.autneu.2006.03.007|s2cid=31388586 }}<!--|access-date=13 June 2015 --></ref> and cardiac autonomic functioning (which has many purposes, including control of heart rate)<ref name="WHO15" /><ref name="Cobb12">{{cite journal |last1=Cobb |first1=CO |last2=Sahmarani |first2=K |last3=Eissenberg |first3=T |last4=Shihadeh |first4=A |title=Acute toxicant exposure and cardiac autonomic dysfunction from smoking a single narghile waterpipe with tobacco and with a "healthy" tobacco-free alternative |journal=Toxicology Letters |date=2012 |volume=215 |issue=1 |pages=70–75 |doi=10.1016/j.toxlet.2012.09.026 |pmid=23059956 |pmc=3641895}}<!--|access-date=2012--></ref><ref name="StHelen14">{{cite journal |last1=St Helen |first1=G |last2=Benowitz |first2=NL |last3=Dains |first3=KM |last4=Havel |first4=C |last5=Peng |first5=M |last6=Jacob |first6=P |title=Nicotine and carcinogen exposure after water pipe smoking in hookah bars |journal=Cancer Epidemiol Biomarkers Prev |date=2014 |volume=23 |issue=6 |pages=1055–66 |doi=10.1158/1055-9965.EPI-13-0939 |pmid=24836469 |pmc=4047652}}<!--|access-date=13 June 2015--></ref> Hookah use also acutely harms vascular functioning,<ref name="Alomari14" /> increases [[inflammation]],<ref name="Hakim11">{{cite journal |last1=Hakim |first1=F |last2=Hellou |first2=E |last3=Goldbart |first3=A |last4=Katz |first4=R |last5=Bentur |first5=Y |last6=Bentur |first6=L |title=The acute effects of water-pipe smoking on the cardiorespiratory system |journal=Chest |date=April 2011 |volume=139 |issue=4 |pages=775–81 |pmid=21030492 |doi=10.1378/chest.10-1833}}<!--|access-date=13 June 2015 --></ref> and harms lung function and reduces the ability to exercise.<ref name="Hawari13">{{cite journal |last1=Hawari |first1=FI |last2=Obeidat |first2=NA |last3=Ayub |first3=H |last4=Ghonimat |first4=I |last5=Eissenberg |first5=T |last6=Dawahrah |first6=S |last7=Beano |first7=H |title=The acute effects of waterpipe smoking on lung function and exercise capacity in a pilot study of healthy participants |journal=Inhalation Toxicology |date=August 2013 |volume=25 |issue=9 |pages=492–7 |pmid=23905967 |doi=10.3109/08958378.2013.806613|bibcode=2013InhTx..25..492H |s2cid=22728685 }}<!--|access-date=13 June 2015 --></ref>

=== Long-term health effects ===
Current evidence indicates hookah causes numerous health problems.<ref name="WHO15" /><ref name="ElZaatari15" /><ref name="Akl10" /><ref>{{Cite web|last=CDCTobaccoFree|date=2021-04-23|title=Hookahs|url=https://www.cdc.gov/tobacco/data_statistics/fact_sheets/tobacco_industry/hookahs/index.htm|access-date=2021-10-13|website=Centers for Disease Control and Prevention|archive-date=7 October 2021|archive-url=https://web.archive.org/web/20211007015136/https://www.cdc.gov/tobacco/data_statistics/fact_sheets/tobacco_industry/hookahs/index.htm|url-status=live}}</ref> Hookah smoking is associated with increased risk of several cancers (lung, esophageal, and gastric), pulmonary diseases (impaired pulmonary function, chronic bronchitis, and [[emphysema]]), [[coronary artery disease]], [[periodontal disease]], obstetrical and perinatal problems (low birth weight and pulmonary problems at birth), larynx and voice changes, and [[osteoporosis]]. Many of the studies to date have methodological limitations, such as not measuring hookah use in a standardized way.<ref name="ElZaatari15" /> Larger, longitudinal studies are needed to learn more about the long-term health effects of hookah use and of exposure to hookah smoke.<ref name="ElZaatari15" /> Oral health is also affected, notably dental and periodontal status.<ref>{{cite journal|last1=Grillo|first1=R|last2=Khemiss|first2=M|last3=Bibars|first3=A|last4=Slusarenko da Silva|first4=Y|date=2023|title=Impact of waterpipe smoking on oral health of users: a systematic review and meta-analysis|journal=Prosthodontics|volume=72|issue=4|pages=322–332|doi=10.5114/PS/157370|s2cid=254625804|doi-access=free}}</ref>

=== Effects of secondhand exposure to hookah smoke ===
[[Secondhand smoke]] from hookahs contains significant amounts of carbon monoxide, aldehydes, PAHs, ultrafine particles, and respirable particulate matter (particles small enough to enter the lungs).<ref name="WHO15" /> Studies have found that concentrations of particulate matter in the air of hookah bars were in the unhealthy to hazardous range according to [[Environmental Protection Agency|the U.S. Environmental Protection Agency]] standards.<ref name="Kumar15">{{cite journal|last1=Kumar|first1=SR|last2=Davies|first2=S|last3=Weitzman|first3=M|last4=Sherman|first4=S|title=A review of air quality, biological indicators and health effects of second-hand waterpipe smoke exposure |journal=Tobacco Control|date=March 2015|volume=24|issue=Suppl 1 |pages=i54–i59|pmid=25480544|doi=10.1136/tobaccocontrol-2014-052038|pmc=4345792}}<!--|access-date=13 June 2015--></ref> The air in hookah bars also contains significant amounts of toxic chemicals, including aromatic hydrocarbons, carbon monoxide, nicotine, and trace metals. The concentrations in the air of all these toxic substances are greater than for cigarettes (for the same number of smokers per hour).<ref name="Daher15">{{cite journal|last1=Daher|first1=N|last2=Saleh|first2=R|last3=Jaroudi|first3=E|last4=Sheheitli|first4=H|last5=Badr|first5=T|last6=Sepetdjian|first6=E|last7=Al Rashidi|first7=M|last8=Saliba|first8=N|last9=Shihadeh|first9=A|title=Comparison of carcinogen, carbon monoxide, and ultrafine particle emissions from narghile waterpipe and cigarette smoking: Sidestream smoke measurements and assessment of second-hand smoke emission factors |journal=Atmospheric Environment|date=1 January 2010|volume=44|issue=1|pages=8–14|pmid=20161525|doi=10.1016/j.atmosenv.2009.10.004|pmc=2801144|bibcode=2010AtmEn..44....8D}}<!--|access-date=13 June 2015--></ref> During a typical one-hour hookah session, a user expels into the air 2-10 times the amount of cancer-causing chemicals and other harmful chemicals compared to a cigarette smoker.<ref name="Daher15" /> No studies have examined the long-term health effects of exposure to secondhand hookah smoke, but short term effects may include experience respiratory symptoms such as wheezing, nasal congestion, and chronic cough.<ref name="Tamin03">{{cite journal|last1=Tamim|first1=H|last2=Musharrafieh|first2=U|last3=El Roueiheb|first3=Z|last4=Yunis|first4=K|last5=Almawi|first5=WY|title=Exposure of children to environmental tobacco smoke (ETS) and its association with respiratory ailments |journal=The Journal of Asthma|date=2003|volume=40|issue=5|pages=571–6|pmid=14529107|doi=10.1081/jas-120019029|s2cid=35129626}}<!--|access-date=13 June 2015--></ref><ref name="Zeidan14">{{cite journal|last1=Zeidan|first1=RK|last2=Rachidi|first2=S|last3=Awada|first3=S|last4=El Hajje|first4=A|last5=El Bawab|first5=W|last6=Salamé|first6=J|last7=Bejjany|first7=R|last8=Salameh|first8=P|title=Carbon monoxide and respiratory symptoms in young adult passive smokers: a pilot study comparing waterpipe to cigarette |journal=International Journal of Occupational Medicine and Environmental Health|date=August 2014|volume=27|issue=4|pages=571–82|pmid=25012596|doi=10.2478/s13382-014-0246-z|doi-access=free}}<!--|access-date=13 June 2015--></ref>