In yet another version of what’s old is new again, water pipe (hookah) tobacco smoking is nouveau-retro-trendy, at least in certain circles. As researchers in Israel have recently shown, not only does smoking tobacco in a hookah provide for efficient nicotine delivery, this practice also leads to alarmingly high levels of carbon monoxide.

This toxic hazard was documented in a simple yet elegant experiment carried out by a research team led by Dr. Yedidia Bentur, who works closely with Israel’s main poison control center. A few years ago, he had shown that simply 30 minutes of smoking tobacco using a water pipe (also known as a hookah, narghile, shisha or even goza, depending on where you are),  could lead to carbon monoxide levels in the blood effecting as high a level as 26% of the circulating hemoglobin ( Indeed, three of 45 participants in Bentur’s earlier study manifested carbon monoxide levels above 20%, which is high enough to get any emergency room provider’s attention. In fact, at 20% or above, serious compromise to the heart and brain can occur, and that assumes that one has a normal amount of functional hemoglobin to begin with.  A case that came into a hospital ER in Ankara, Turkey makes the point. A 25-year-old man complained of headache, vomiting, and vertigo, several hours after a 2-hour session of water pipe smoking in narghile café. The patient’s carbon monoxide level was just under 29%. The report is careful to note that it was winter-time. (

Hemoglobin in our blood cells is what carries the oxygen from the lungs to every part of the body. Carbon monoxide is a toxic gas that stops that from happening. That’s why carbon monoxide alarms have been mandated in homes and that’s why they save lives. So what’s the problem with a water pipe? Like many hazards, it arises from the technology of the device. Technology may sound like a high-falutin term applied to a hookah but, in fact, it is key to the problem: burning charcoal, placed above the tobacco to be smoked (typically with a piece of perforated aluminum foil in between) supplies the heat of combustion and is an important source of carbon monoxide, adding to what is already produced simply through burning tobacco. Smoking tobacco using a cigarette as the delivery device does produce carbon monoxide too, but not nearly as much.

Bentur’s new water pipe experiment had one key innovation. A cue came from the Ankara emergency room report. During winter, a café’s doors and windows are likely to be kept closed.  The last time around the study protocol had the participant smoking outside, on a balcony. This time, the smoking took place in a closed space with one open window (actually, the waiting room of the pediatric lung disease unit at the hospital, one presumes after-hours). No surprise, the carbon monoxide levels were even higher – in two participants as high as 40% or more. That’s a level at which some people exposed to carbon monoxide lose consciousness and warrant treatment in a hyperbaric chamber.

Needless to say there are other ways of unintentionally gassing oneself with carbon monoxide. Cooking on a hibachi in the kitchen, for example, is a very very bad idea. But that misguided practice is not cool, whereas water pipe cafés are. Maybe even groovy. A critical response came in to the journal that published the Ankara report of the posioned cafe patron ( Its author, writing from France, did not contend that water pipe smoking is not a problem, referring to “one thousand neo-orientalist narghile smoking tea houses” in his country, but he does argue that this is not due to transplanted practices. Thus, in the convoluted wording of the writer, “Hookah spread across the globe over the past two decades further to a complex synergistic reaction involving many socio-anthropological factors and in which migration flows did not play an independent role by themselves.”

So let’s not call in the folks from Homeland Security. How about regulators from the FDA? Oh that’s right - they’re too busy doing nothing about electronic cigarettes.

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