Is one hookah really 100 cigarettes? What's true and what isn't

Hookah myths & facts Part 1

“One hookah is like a hundred cigarettes.” You've heard it from your parents, from a friend who doesn't smoke, maybe from a doctor. The number is twenty years old and partly true. The problem is that nobody says what it refers to. Here's what has actually been measured, with no spin in either direction.

Where the number “100 cigarettes” comes from

From 2005. That year the World Health Organization published its first advisory note on waterpipe smoking and compared smoke volume: how much a smoker inhales in one session versus one cigarette. An hour-long session is about 200 puffs, a cigarette about 20. Each hookah puff is deeper and longer, so around 90 liters of smoke pass through the lungs, against half a liter from a cigarette. That's how you get a hundred or more “cigarettes”. The US CDC still quotes the same figures, and the second edition of the WHO note puts the estimate at 100 to 200 times more smoke.

That comparison measures only the amount of smoke. Not what's in it, and not how much of it the body keeps. That's why the number doesn't match what blood tests show, and why it's easy to both overstate and dismiss. “One hookah is a hundred cigarettes” is true for smoke and false for nicotine.

Nicotine: what the blood shows

In 2009 Thomas Eissenberg of Virginia Commonwealth University and Alan Shihadeh of the American University of Beirut did something nobody had done before: they gave the same people both a hookah and a cigarette, then tested their blood. Thirty-one smokers who use both. One day 45 minutes of hookah, another day a single cigarette, smoked in five or six minutes.

Peak nicotine in blood: 10.2 nanograms per milliliter after hookah, 10.6 after the cigarette. Practically the same. Two years later the same team repeated the experiment with 54 people: 9.8 versus 9.4. Same again.

So in nicotine terms, 45 minutes of hookah is in the range of one cigarette. A 2016 review of 17 studies (Primack and colleagues, University of Pittsburgh) puts it at “two or three cigarettes' worth”, because it depends on the tobacco, the length of the session and how hard you pull. Not a hundred. Not even close.

But watch the other side. Same nicotine, same addiction. Hookah tobacco is real tobacco with molasses, and strawberry or mint doesn't change the nicotine. Hookah doesn't get you “high” on anything else either: what a beginner feels after the first few puffs is nicotine reaching the brain in about ten seconds, plus the carbon monoxide covered below.

Carbon monoxide: where hookah loses

The same experiments also measured how much carbon monoxide had bound to the blood (carboxyhemoglobin). After a cigarette 1.3 percent, after hookah 3.9 percent, three times as much. In the repeat study 4.5 versus 1.2 percent, almost four times. That's what gets you: dizziness, nausea, headache, sometimes fainting.

Carbon monoxide doesn't come from the tobacco but from the charcoal. The tobacco in a hookah doesn't burn, it only gets heated, while the charcoal burns for a full hour and you breathe it in through the bowl. Quick-light coals produce about twice as much carbon monoxide as natural coconut charcoal, according to a 2015 measurement. See where the coals sit on the 3D model, and how to light them without smoke and smell in our guide on how to set up a hookah. Hookah headaches will get their own post in this series.

Tar, metals and water

The Pittsburgh review added it all up: one hookah session delivers on average 74 liters of smoke, one cigarette 0.6. Along with the smoke come tar and carbon monoxide, both more than from a single cigarette. Serbia's Batut public health institute puts it this way: 45 to 60 minutes of hookah exposes the body to as much tar and carbon monoxide as a whole pack of cigarettes.

And the water? It cools and moistens the smoke, so it's smoother on the throat. It doesn't clean it. In a 2015 measurement from Jordan, the water retained about 3 percent of the heavy metals from the tobacco (copper, chromium, lead), 57 percent made it into the smoke and the rest stayed in the ash. We'll cover that one separately, because it's myth number one.

What's true and what isn't

Count per week, not per session

Per-session comparisons mislead, because nobody smokes hookah like cigarettes. A pack-a-day smoker goes through 140 cigarettes a week. Someone who goes for hookah on Friday and Saturday has two sessions: nicotine like two to six cigarettes, much more smoke and carbon monoxide than that, but still far below a pack a day.

The math changes when hookah becomes daily. One study from the Middle East, where people smoke it every day, found that people with two hookahs a day had the same level of cotinine in their urine (what nicotine breaks down into) as smokers of 30 cigarettes a day. So: the occasional hookah and hookah as a habit are not the same story, and that's the only fair comparison with cigarettes.

What you can do

1. Shorter session. Half an hour instead of an hour and a half. Smoke and carbon monoxide add up by the minute, not by the bowl.
2. Natural charcoal. Coconut cubes instead of quick-light, no exceptions at home. At a lounge, feel free to ask what they use.
3. Fresh air. Carbon monoxide builds up indoors. A garden table or one by the door isn't a bad choice even in winter.
4. Not on an empty stomach. And keep water or tea next to the hookah, not just beer.
5. Your own mouthpiece. Disposable or your own from home. A hose that goes around the table passes on cold sores and colds.
6. If you get dizzy, stop. That's not “strong tobacco”, that's carbon monoxide. Step outside and don't keep going “so it doesn't go to waste”.

If you're just starting out, read the beginner's guide first, and which tobaccos are stronger or milder is in our post on the best hookah tobacco brands.

FAQ

This is not medical advice. The figures come from published studies: the World Health Organization (2005, 2015), the US CDC, Eissenberg and Shihadeh (2009), Cobb and colleagues (2011), Primack and colleagues (2016), Al-Kazwini and colleagues (2015), Medford and colleagues (2015) and Serbia's Batut institute.