“Hookah can’t be as addictive as cigarettes, right?” “If I only smoke on weekends, I’m fine, aren’t I?” Because hookah is smoked slowly over a long session, many people assume it is less habit-forming than cigarettes. Others wonder what happens if a relaxing weekend habit slowly turns into hookah every day.
This guide looks at whether hookah is addictive, based on what public health bodies say and what research has reported. It also covers the signs that nicotine may be involved and where you can get help in Japan. It is not medical advice: if you are worried about your own health or habits, please talk to a doctor or pharmacist.
The short answer: yes, hookah can be addictive
Three public health bodies are clear on this point:
- The U.S. Centers for Disease Control and Prevention (CDC) says the nicotine in hookah is the same highly addictive chemical found in other tobacco products.
- The U.S. Food and Drug Administration (FDA) says hookah delivers nicotine, an addictive drug, to the body. According to the FDA, nicotine changes the way the brain works and causes cravings for more.
- The World Health Organization’s Regional Office for the Eastern Mediterranean (WHO EMRO) states plainly that waterpipe tobacco is highly addictive.
In other words, passing the smoke through water, or smoking slowly, does not mean hookah can’t lead to dependence. The nicotine is still there, and it acts on the body in the same way.
How nicotine dependence works
Japan’s Ministry of Health, Labour and Welfare runs a health information site called e-health net. It describes nicotine dependence as a condition in which a person feels discomfort when the nicotine level in their blood drops below a certain point, and so keeps smoking again and again.
The mechanism behind this is fairly simple. When you inhale nicotine, dopamine is released in the brain, and you feel pleasure. When the nicotine wears off, unpleasant withdrawal symptoms appear, and smoking again relieves them. That creates a cycle: smoke, feel good, feel uncomfortable as the effect fades, then smoke again to feel better. This repeating cycle is what dependence is.
Nothing about this mechanism depends on the device. Whether the nicotine comes from a cigarette or from a hookah bowl, the same cycle can take hold.
How much nicotine is in one hookah session?
A single hookah session can involve more nicotine than many people expect. The CDC says that one hookah session may expose you to about 1.7 times the nicotine and about 9 times the carbon monoxide of a single cigarette.
WHO EMRO gives another comparison: the nicotine in one bowl of unflavored tobacco is equivalent to that of 2 to 12 cigarettes.
These figures vary depending on how people smoke and how the measurements were made, so they are not exact predictions for any one session. The safer takeaway is simply that the amount of nicotine per session is not small. For more on how to read these numbers, see Is Hookah Dangerous?.
Dependence can happen even if you don’t smoke every day
Hookah is usually smoked differently from cigarettes. Rather than a set number every day, many people enjoy it on weekends with friends. The UK’s National Centre for Smoking Cessation and Training (NCSCT) also notes that, unlike cigarettes, waterpipes are often smoked intermittently and in groups.
At the same time, the NCSCT says waterpipe tobacco has the potential to cause dependence, and that the pattern of that dependence is likely to differ from cigarette dependence. It points out that sensory cues such as the aroma, the taste and the sound of the bubbling water, as well as social gatherings, can become triggers that make people want to smoke. The NCSCT also cites a study of customers at shisha cafés in London, which found signs of dependence in almost half of them.
Research has reported similar findings.
- Aboaziza and Eissenberg (2015): this review concludes that waterpipe smoking supports nicotine and tobacco dependence. The authors base this on three points: it delivers nicotine to the body, some people experience withdrawal symptoms when they stop, and some find it hard to quit even when they want to.
- Bahelah et al. (2017), a study of young people in Lebanon: even among people who smoked hookah less than once a week, 57.3% showed “loss of autonomy,” meaning difficulty controlling how much they smoke, and 18.7% met the criteria for nicotine dependence under the international diagnostic standard ICD-10. Among those who smoked once a week or more (but not daily), the figures were 80% and 46.7%. The study also suggests that longer sessions may be a new indicator of dependence.
Put simply, the research shows that “I don’t smoke every day, so I’m fine” is not a safe assumption.
What about hookah every day?
If people who smoke less than weekly can already show signs of dependence, it is worth taking a daily habit seriously. The figures in the Lebanese study rose sharply between the less-than-weekly group and the weekly (non-daily) group. And the CDC’s comparison above applies to each session, so more sessions mean more nicotine and carbon monoxide over time. If you find yourself reaching for hookah every day, the signs listed below are a useful check.
Is nicotine-free hookah addictive?
Nicotine-free flavors contain no nicotine, so they do not cause nicotine dependence. However, as long as charcoal is used, you are still exposed to smoke and carbon monoxide (CDC). Avoiding nicotine and avoiding any effect on your body are two different things. For more, see Nicotine-Free Shisha.
Signs that nicotine may be involved
Based on the e-health net explanation and the research above, the following may indicate that nicotine dependence is involved:
- You feel uncomfortable, restless or irritable when you go without hookah or cigarettes.
- You often can’t stick to limits you set yourself on how often or how long you smoke.
- You want to stop but find it hard to do so.
Even if one or more of these applies to you, don’t try to diagnose yourself. If you are concerned, talk to a professional.
Where to get help in Japan: smoking cessation clinics and pharmacies
Smoking cessation clinics
In Japanese, a smoking cessation clinic is called 禁煙外来 (kin’en gairai). According to e-health net, if certain conditions are met, treatment is covered by health insurance, with five sessions over 12 weeks. The conditions include:
- A score of 5 or more on the Tobacco Dependence Screener (TDS), a screening test for nicotine dependence.
- For people aged 35 and over, a Brinkman index of 200 or more. This is the number of cigarettes smoked per day multiplied by the number of years of smoking.
- Since 2016, people under 35 have been eligible for insurance coverage regardless of how many cigarettes they smoke per day or how many years they have smoked.
e-health net reports that about 80% of people who completed the 12-week programme had stopped smoking for four weeks or more at the end of treatment.
These rules describe coverage under Japan’s health insurance system. If you are visiting Japan, it is best to ask the clinic directly what applies to you.
Pharmacies and pharmacists
According to e-health net, nicotine gum can be bought at pharmacies in Japan. Nicotine patches are available both over the counter at pharmacies and on prescription from medical institutions. You can ask a pharmacist how to use them.
Because hookah is smoked differently from cigarettes, in both how people smoke and how much, it helps to explain your situation clearly when you ask for advice. Tell the doctor or pharmacist that you smoke hookah (shisha, or 水たばこ, mizu-tabako, in Japanese), and how often and for how long you usually smoke in one session.
Thinking about how often and how long you smoke
If you are thinking about your own relationship with hookah, here is what public health information and research can tell you:
- Hookah carries a risk of nicotine dependence (CDC, FDA, WHO EMRO).
- Signs of dependence have been found in people who don’t smoke every day (Bahelah et al.).
- The longer a session lasts, the more exposure to nicotine and carbon monoxide there may be (CDC, Bahelah et al.).
- The younger people are when they start smoking, the more of them become highly dependent (e-health net). In Japan, smoking is prohibited for anyone under 20 (Hookah Age Limit in Japan).
For a guide to how long one hookah typically lasts, see How Long Does a Hookah Last?. For how hookah compares with cigarettes, heated tobacco and e-cigarettes, see Hookah vs Cigarettes.
FAQ
Is hookah addictive?
Yes. The CDC, the FDA and WHO EMRO all say that hookah can be addictive because it contains nicotine, the same addictive chemical found in other tobacco products.
Is it OK if I only smoke hookah on weekends?
Research has reported signs of dependence even among people who smoke less than once a week (Bahelah et al., 2017). Smoking infrequently does not mean there is no risk of dependence.
What happens if I smoke hookah every day?
Each session can expose you to more nicotine and carbon monoxide than a single cigarette (CDC), and dependence has been reported even in people who smoke far less often (Bahelah et al., 2017). If you smoke daily and notice the signs above, consider talking to a doctor or pharmacist.
Is hookah less addictive than cigarettes?
The NCSCT says the pattern of dependence is likely to differ from cigarettes, but hookah still has the potential to cause dependence.
Can I get help at a smoking cessation clinic if I only smoke hookah?
Insurance coverage depends on conditions, such as the TDS score. Start by telling the clinic that you smoke hookah and ask for advice.
Summary
- The nicotine in hookah is addictive (CDC, FDA, WHO EMRO).
- One session may expose you to more nicotine than a single cigarette (CDC).
- Studies have found signs of dependence in people who don’t smoke every day.
- Nicotine-free hookah won’t cause nicotine dependence, but smoke and carbon monoxide remain.
- If you’re concerned, talk to a smoking cessation clinic or a pharmacist.
How it works at shisha bar IORI (Gakugei-daigaku, Tokyo)
- For guests who want to avoid nicotine, we offer 36 nicotine-free flavors. Our staff are happy to help you choose
- We ventilate the room thoroughly and check indoor carbon monoxide levels regularly with a CO monitor
- Ages 20+ only
References
- Centers for Disease Control and Prevention, “Hookahs”
- U.S. Food and Drug Administration, “Hookah Tobacco (Shisha or Waterpipe Tobacco)”
- WHO EMRO, “Tobacco Free Initiative fact sheet: waterpipe tobacco smoking”
- NCSCT, “Waterpipe tobacco smoking: briefing”
- Aboaziza E, Eissenberg T. Tobacco Control, 2015 (evidence on waterpipe smoking and nicotine dependence)
- Bahelah R, et al. Addictive Behaviors, 2017 (waterpipe dependence among young people in Lebanon)
- Ministry of Health, Labour and Welfare e-health net, “Nicotine dependence” (Japanese)
- Ministry of Health, Labour and Welfare e-health net, “What is smoking cessation treatment?” (Japanese)
- Ministry of Health, Labour and Welfare e-health net, “Smoking cessation medications” (Japanese)
- Ministry of Health, Labour and Welfare e-health net, “Young people’s health and smoking” (Japanese)
