“I felt dizzy halfway through.” “I got a headache and started feeling sick.” If hookah has ever left you feeling unwell, there are two main suspects: nicotine and carbon monoxide (CO). The second one in particular should never be brushed off: people have lost consciousness after leaving hookah venues.
This guide explains the difference between the two, what to do on the spot, when to call for an ambulance in Japan, and how to lower the risk, based on information from public health agencies.
This article is general information, not medical advice. In an emergency in Japan, call 119 for an ambulance. If you are unsure whether to call, many areas of Japan run a medical advice line on #7119, where doctors and nurses give advice by phone and can transfer your call to 119 if needed.
What is the “nicotine rush”?
The light-headed, woozy feeling some people get from tobacco is often called a “nicotine rush” or “head rush.” It is slang, not a medical term.
Nicotine reaches the brain quickly after it is inhaled. It also narrows blood vessels and raises blood pressure, according to Japan’s Ministry of Health, Labour and Welfare, which also notes that non-smokers, who have no tolerance to nicotine, are more likely to experience symptoms such as nausea and dizziness.
But nicotine is not always the culprit. The UK’s National Centre for Smoking Cessation and Training (NCSCT) points out that the “buzz” hookah users often describe may reflect the early stages of carbon monoxide poisoning.
What is carbon monoxide poisoning?
Hookah uses burning charcoal to heat the tobacco or herbal mixture. Carbon monoxide is produced by the charcoal and the burning mixture, and it is a colorless, odorless gas, so you cannot tell it is there. A review of hookah-related CO poisoning cases concluded that CO levels are high primarily because charcoal is the heat source (Retzky, 2017).
For coal types, coal changes and why most carbon monoxide comes from the charcoal, see Hookah Charcoal Explained.
Common symptoms
The U.S. Centers for Disease Control and Prevention (CDC) and the UK’s National Health Service (NHS) list symptoms including:
- Headache
- Dizziness
- Feeling sick or vomiting
- Weakness
- Chest pain or shortness of breath
- Confusion
Breathing in a lot of CO can make you pass out or kill you (CDC). The NHS notes that symptoms may get worse when you spend time in the affected room and improve when you leave it.
Real cases in Japan
Japan’s Consumer Affairs Agency has described a hookah customer who lost consciousness and fell just after leaving a venue and was diagnosed with CO poisoning, and a person in their twenties who felt short of breath after leaving, then could not stand after getting off a train and lost consciousness.
In a survey published by the Tokyo Metropolitan Government in March 2025, 36.2% of people who had smoked hookah and 22.2% of people who had been in the same space reported experiences such as feeling unwell. In Tokyo’s tests, CO in a closed room reached levels that cause headaches and nausea within one to two hours. The people around you can be affected too, not just the person smoking.
Why hookah in particular?
Carbon monoxide is not unique to hookah, but a few things about hookah make it more of a concern:
- The heat source is charcoal. A review of reported cases found that CO exposure from hookah is high primarily because charcoal is used to heat the tobacco (Retzky, 2017).
- Sessions are long. A single session burns for around an hour (Consumer Affairs Agency), so CO keeps being produced the whole time.
- The volume of smoke is large. The CDC estimates that one session exposes a smoker to nearly nine times the carbon monoxide of a single cigarette.
Nicotine or carbon monoxide: can you tell?
| Nicotine effects | Carbon monoxide poisoning | |
|---|---|---|
| Cause | Nicotine in tobacco | CO from burning charcoal and the mixture |
| Happens with nicotine-free hookah? | No | Yes |
| Typical symptoms | Nausea, dizziness | Headache, dizziness, nausea, shortness of breath, confusion |
| Who is affected | Mainly the smoker | Anyone in the same room |
The symptoms overlap, so assume you cannot reliably tell them apart on the spot. Nicotine-free hookah still produces carbon monoxide (CDC), so “there’s no nicotine in it” does not mean you are in the clear.
When it’s more likely
Public health information points to a few situations that call for extra care:
- Poor ventilation. Tokyo and the Consumer Affairs Agency both urge users to check that a venue is well ventilated.
- Long sessions. A single session burns for around an hour (Consumer Affairs Agency), producing CO the whole time.
- Not being used to tobacco. Non-smokers are more prone to nausea and dizziness from nicotine (Ministry of Health, Labour and Welfare).
- Being drunk. The CDC warns that people who are intoxicated may die from CO poisoning before they recognize the symptoms.
Drinking too? See Hookah and Alcohol: What to Know Before Drinking While You Smoke.
How long does hookah sickness last?
There is no official figure for how long a “nicotine rush” lasts, and the public sources in this guide do not give one for hookah sickness either. What they do say is useful:
- Symptoms can ease when you leave. The NHS notes that CO symptoms may get worse while you stay in the affected room and improve when you leave it.
- Feeling better is not the same as being safe. Japan’s Consumer Affairs Agency has described people who lost consciousness after leaving a hookah venue, including one who collapsed after getting off a train.
- Get checked if you had symptoms. The Japan Poison Information Center advises seeing a doctor promptly if you have had symptoms such as dizziness or headache.
So rather than waiting to see how long it lasts, stop smoking, get to fresh air, and follow the steps below. If any of the warning signs listed under “When to call 119” appear, call straight away.
What to do on the spot
If something feels wrong, act straight away:
- Stop smoking. Japan’s Consumer Affairs Agency advises stopping immediately if you notice symptoms such as confusion, headache or nausea.
- Get to fresh air. The CDC advises moving to fresh air and seeking medical help immediately if CO poisoning is suspected.
- Tell someone. Let the staff or your friends know instead of toughing it out alone.
- Don’t drive. The CDC’s occupational health institute (NIOSH) advises having someone else drive you rather than driving yourself.
- Get checked if you have symptoms. The Japan Poison Information Center advises seeing a doctor promptly if you have symptoms such as dizziness or headache.
When to call 119
Japan’s Fire and Disaster Management Agency lists symptoms in adults that warrant calling 119 without hesitation, including:
- Unconsciousness or no response, or being confused and drowsy
- A sudden, severe headache
- Sudden unsteadiness so bad you cannot stand without support
- Sudden shortness of breath or difficulty breathing
- Strong nausea accompanied by a cold sweat
If you are not sure whether to call, contact #7119 where available. Doctors, nurses and other staff give advice by phone and transfer the call to 119 if it is urgent.
Calling 119 as a visitor
Japan’s Fire and Disaster Management Agency publishes an English guide to calling an ambulance. When you dial 119, the operator will first ask whether it is a fire or a medical emergency. The guide recommends that you:
- Say it is a medical emergency.
- Give the address where the ambulance should come. If you don’t know it, describe a nearby building or intersection; venue staff can usually help with the address.
- Explain the symptoms: who is affected, how they are now, and whether they are conscious and breathing.
- Give the person’s age (an approximate age is fine).
- Give your name and a phone number you can be reached on.
The guide also suggests having your passport ready if you can, and speaking slowly.
How to lower the risk
- Choose a well-ventilated venue and seat. Tokyo recommends running extractor fans or opening doors and windows to lower indoor CO levels.
- Smoke slowly, with breaks. Don’t draw continuously (How to Smoke Hookah Properly covers the technique).
- Skip it when you’re not feeling well.
- Keep an eye on the people you’re with. They can be affected too.
- Speak up. Tell the staff as soon as you feel unwell.
FAQ
Will nicotine-free hookah stop me feeling sick?
It removes the nicotine effect, but charcoal still produces carbon monoxide, so CO poisoning remains a risk.
I felt better after a short rest. Do I still need to see a doctor?
People have lost consciousness after leaving hookah venues. The Japan Poison Information Center advises seeing a doctor if you have had symptoms such as dizziness or headache. If you are unsure, call #7119 where available.
My friend has a headache too. What should we do?
People sharing the room can also be affected by CO (Tokyo Metropolitan Government). Move everyone to fresh air and get anyone with symptoms checked.
Summary
- Feeling sick from hookah usually comes down to nicotine or carbon monoxide.
- The “nicotine rush” is slang; a light-headed feeling can also be an early sign of CO exposure.
- CO is colorless and odorless, is produced even by nicotine-free hookah, and affects everyone in the room.
- If you feel unwell, stop, get fresh air and seek medical care. Call 119 for serious symptoms, or #7119 if unsure.
- Good ventilation, a slow pace and only smoking when you feel well all help.
For the wider picture, read Is Hookah Dangerous? Risks, Myths and How to Reduce Them, and for the basics, What Is Hookah (Shisha)? A Beginner’s Guide to Trying It in Japan.
How it works at shisha bar IORI (Gakugei-daigaku, Tokyo)
- If you feel unwell at any point, please tell our staff straight away
- We ventilate the room thoroughly and check indoor carbon monoxide levels regularly with a CO monitor
- 36 nicotine-free flavors are available for guests who want to avoid nicotine
- Ages 20+ only
References
- Centers for Disease Control and Prevention, “Carbon Monoxide Poisoning Basics”
- CDC/NIOSH, “Carbon Monoxide”
- Centers for Disease Control and Prevention, “Hookahs”
- NHS, “Carbon monoxide poisoning”
- NCSCT, “Waterpipe tobacco smoking: briefing”
- Retzky SS. “Carbon Monoxide Poisoning from Hookah Smoking: An Emerging Public Health Problem.” Journal of Medical Toxicology, 2017
- Ministry of Health, Labour and Welfare, guide to nicotine replacement products (Japanese)
- Ministry of Health, Labour and Welfare, e-healthnet “Nicotine” (Japanese)
- Consumer Affairs Agency, warning on carbon monoxide poisoning from waterpipes, May 2023 (Japanese)
- Consumer Affairs Agency, waterpipe warning for World No Tobacco Week, May 2026 (Japanese)
- Tokyo Metropolitan Government press release, March 2025 (Japanese)
- Japan Poison Information Center, “Carbon monoxide” (Japanese)
- Fire and Disaster Management Agency, “Making the Most of the Ambulance Service” (English)
- Fire and Disaster Management Agency, guide to using ambulances (Japanese)
- Fire and Disaster Management Agency, #7119 emergency advice service (Japanese)
