This article is not medical advice. If you have any worries or questions about smoking or secondhand smoke during pregnancy or breastfeeding, please talk to your own doctor or midwife.
If you are pregnant or breastfeeding, you may be wondering whether hookah (also called shisha or waterpipe) is something to avoid, whether nicotine-free flavors make a difference, or whether it matters if you simply sit in a room where other people are smoking. These are common questions, especially for travelers who come across hookah lounges in Japan and are not sure what the local guidance says.
This guide brings together what public health bodies and medical societies in Japan and abroad have said on the topic. It draws only on official sources: the U.S. Centers for Disease Control and Prevention (CDC), the World Health Organization’s Regional Office for the Eastern Mediterranean (WHO EMRO), Japan’s Ministry of Health, Labour and Welfare (through its e-health net information site), Japan’s Children and Families Agency, the Japan Society of Obstetrics and Gynecology, and the Tokyo Metropolitan Government. We summarize what each body says and attribute every point to its source, without adding our own judgments on safety.
What public health bodies say: at a glance
Here is a short summary of the key points before we look at each topic in more detail:
- The CDC says that babies born to people who smoked hookah daily during pregnancy may have a lower birth weight than babies born to people who did not smoke, and that babies born to people who use hookah have a higher risk of respiratory illness.
- WHO EMRO says that both using a waterpipe and being exposed to secondhand waterpipe smoke can harm pregnancy.
- A guideline included in the Children and Families Agency’s “Support Guide for Breastfeeding and Weaning” says that smoking, secondhand smoke and drinking alcohol during pregnancy and breastfeeding affect the development of the fetus and the infant and the production of breast milk. It encourages people to try not to smoke or drink, and to ask those around them for their cooperation.
Smoking during pregnancy
What is said about hookah specifically
The CDC’s page on hookahs includes two points that relate directly to pregnancy:
- Babies born to people who smoked hookah every day while pregnant may weigh less at birth than babies born to people who did not smoke.
- Babies born to people who use hookah have a higher risk of respiratory illness.
WHO EMRO, in its fact sheet on waterpipe tobacco smoking, also says that waterpipe use, and exposure to secondhand waterpipe smoke, can harm pregnancy.
In other words, two major public health bodies have each addressed hookah and pregnancy directly, rather than only talking about cigarettes. Hookah is sometimes seen as a separate, more social activity, but these sources treat it as something that can affect a pregnancy too.
What is said about smoking in general
Public bodies and medical societies also give the following information about smoking during pregnancy in general:
- The CDC: smoking during pregnancy raises the risk of health problems for the baby, including preterm birth, low birth weight, and birth defects of the mouth and lip. The CDC also says that nicotine is a health danger for pregnant people and can damage a developing baby’s brain and lungs.
- Japan’s Ministry of Health, Labour and Welfare (e-health net): the longer a person smokes during pregnancy, the higher the risk of preterm birth, and the more cigarettes smoked, the lower the baby’s birth weight and length.
- The Japan Society of Obstetrics and Gynecology: in its declaration on smoking, the society says that smoking is a serious factor that harms women’s health and also affects children through pregnancy and childbirth. It states that it works toward reducing smoking and secondhand smoke exposure among pregnant women to zero.
These points refer to smoking in general rather than to hookah alone. We include them because they are the general guidance these bodies give on smoking and pregnancy.
If the hookah is nicotine-free
Nicotine-free flavors do not contain nicotine. However, the CDC says that the smoke from both tobacco-based hookah and herbal (nicotine-free) hookah contains harmful substances such as carbon monoxide.
Hookah is heated with charcoal, so even when the flavor is nicotine-free, the session still produces smoke and carbon monoxide. Taking the nicotine out does not take the charcoal out, and the charcoal is where the carbon monoxide comes from.
For more on nicotine-free shisha, see What Is Nicotine-Free (Herbal) Shisha? Ingredients, Types and What It Doesn’t Change.
If you are in the same room (secondhand smoke)
Even if you do not smoke yourself, being in a place where there is hookah smoke is also addressed by public bodies:
- WHO EMRO: exposure to secondhand waterpipe smoke can also harm pregnancy.
- The CDC: secondhand hookah smoke contains not only tobacco smoke but also smoke from the heat source, such as charcoal. The CDC also says that exposure to secondhand smoke during pregnancy lowers birth weight.
- Japan’s Ministry of Health, Labour and Welfare (e-health net): secondhand smoke during pregnancy is regarded as a definite factor in sudden infant death syndrome (SIDS), and links with low birth weight and fetal growth restriction have also been pointed out.
- The Tokyo Metropolitan Government: on carbon monoxide from hookah, Tokyo says that in an enclosed space there is a risk of carbon monoxide poisoning not only for the person smoking but also for the people around them.
So the question is not only whether you inhale from the hose yourself. According to these sources, the smoke in the room, and the carbon monoxide from the charcoal, are also relevant.
Japan’s rules on secondhand smoke, and who can enter smoking areas, are covered in Hookah Age Limit in Japan: Why It’s 20, Not 18, and Why Under-20s Can’t Enter. In Japan, the legal smoking age is 20.
If you are wondering whether you can bring children or a baby to a hookah bar, see Can Kids Go to a Hookah Bar in Japan? Children, Babies and Under-20s Explained.
For secondhand hookah smoke in general, see Hookah Secondhand Smoke.
While breastfeeding
The “Dietary Guidelines for Pregnant and Nursing Women,” included in the Children and Families Agency’s “Support Guide for Breastfeeding and Weaning,” say that smoking, secondhand smoke and drinking alcohol during pregnancy and breastfeeding affect the development of the fetus and the infant and the production of breast milk. The guidelines encourage people to try not to smoke or drink, and to ask those around them for their cooperation.
That last point is worth noting: the guidance is not only addressed to the person who is breastfeeding. It also asks partners, family members and others nearby to help, because secondhand smoke is included alongside smoking.
The CDC also lists infants among the people who are more likely to become ill from carbon monoxide.
About carbon monoxide
Because hookah uses charcoal, it produces carbon monoxide. The CDC says that one hookah session can expose you to about nine times as much carbon monoxide as a single cigarette.
This applies whether the flavor contains nicotine or not, since the carbon monoxide comes from the charcoal. For the symptoms of carbon monoxide poisoning and what to do if you feel unwell, see Feeling Sick After Hookah? Nicotine vs Carbon Monoxide, and What to Do.
For an overview of hookah’s risks in general, see Is Hookah Dangerous? Risks, Myths and How to Reduce Them.
Where to get advice
- If you have any worries or questions about smoking or secondhand smoke during pregnancy or breastfeeding, please talk to your own doctor or midwife.
- If you are thinking about quitting smoking, Japan’s Ministry of Health, Labour and Welfare (e-health net) describes quit-smoking treatment offered at smoking cessation clinics. For any treatment or medication, tell your doctor that you are pregnant or breastfeeding and ask for their advice.
If you are visiting Japan, your own doctor or midwife back home, who knows your situation, is a good first point of contact for these questions.
If you take hormonal birth control, see Hookah and Birth Control.
FAQ
Is nicotine-free hookah fine during pregnancy?
Nicotine-free flavors do not contain nicotine, but the CDC says that the smoke from herbal (nicotine-free) hookah also contains harmful substances such as carbon monoxide. If you are worried, please talk to your doctor.
What if I don’t smoke and just sit in the same room?
WHO EMRO says that exposure to secondhand waterpipe smoke can also harm pregnancy. Japan’s Ministry of Health, Labour and Welfare (e-health net) points to links between secondhand smoke during pregnancy and low birth weight and fetal growth restriction, among other things.
What about while breastfeeding?
A guideline included in the Children and Families Agency’s guide says that smoking and secondhand smoke while breastfeeding affect the infant’s development and the production of breast milk. For specific questions, please talk to your doctor or midwife.
Does the charcoal matter if nobody is smoking tobacco?
Yes, according to the sources above. The CDC says hookah smoke, including herbal hookah smoke, contains carbon monoxide, and that secondhand hookah smoke includes smoke from the heat source such as charcoal. Tokyo also warns of a carbon monoxide poisoning risk for people around the smoker in an enclosed space.
Is a baby more sensitive to carbon monoxide?
The CDC lists infants among the people who are more likely to become ill from carbon monoxide.
Summary
- The CDC says babies born to people who smoked hookah daily during pregnancy may have a lower birth weight, and babies born to people who use hookah have a higher risk of respiratory illness.
- WHO EMRO says waterpipe use and secondhand waterpipe smoke can harm pregnancy.
- Even nicotine-free hookah produces smoke and carbon monoxide (CDC).
- Secondhand smoke during pregnancy has been linked to SIDS, low birth weight and fetal growth restriction (e-health net).
- Smoking and secondhand smoke while breastfeeding affect the infant’s development and breast milk production (Children and Families Agency guide).
- If you have worries or questions, talk to your doctor or midwife.
How it works at shisha bar IORI (Gakugei-daigaku, Tokyo)
- Ages 20+ only
- We ventilate the room thoroughly and check indoor carbon monoxide levels regularly with a CO monitor
- If you have any concerns, please ask our staff
References
- Centers for Disease Control and Prevention, “Hookahs”
- Centers for Disease Control and Prevention, “Substance Use During Pregnancy”
- Centers for Disease Control and Prevention, “Cigarettes and Reproductive Health”
- Centers for Disease Control and Prevention, “Carbon Monoxide Poisoning Basics”
- WHO EMRO, “Tobacco Free Initiative fact sheet: waterpipe tobacco smoking”
- Ministry of Health, Labour and Welfare e-health net, “Women’s smoking, secondhand smoke, and pregnancy and childbirth” (Japanese)
- Ministry of Health, Labour and Welfare e-health net, “What is quit-smoking treatment?” (Japanese)
- Children and Families Agency, “Support Guide for Breastfeeding and Weaning” (2019 revision) (Japanese)
- Japan Society of Obstetrics and Gynecology, “Our declaration on smoking” (Japanese)
- Tokyo Metropolitan Government press release (March 2025), “Waterpipes (shisha) carry a risk of carbon monoxide poisoning” (Japanese)
