“Is hookah actually bad for you?” “Isn’t it gentler than cigarettes?” Plenty of people ask these questions before trying hookah (shisha) for the first time.
Here is the short answer first: hookah is a tobacco product, and it is not harmless. Passing smoke through water does not filter it, and the charcoal used to heat it produces carbon monoxide. At the same time, how much risk you take on depends on how often you smoke, for how long, and how well ventilated the space is. This guide sets out what public health agencies say, the most common myths, and practical ways to reduce the risk. It is general information, not medical advice; if you have health concerns, talk to a doctor.
What public health agencies say
- The U.S. Food and Drug Administration (FDA) states that there are no safe tobacco products.
- The World Health Organization’s Regional Office for the Eastern Mediterranean (WHO EMRO) states that waterpipe smoking is not a safe alternative to cigarettes.
- The U.S. Centers for Disease Control and Prevention (CDC) says hookah smoke contains nicotine, tar and heavy metals, and that the charcoal can produce high levels of carbon monoxide, metals and cancer-causing chemicals.
Five common myths
Myth 1: The water filters out the harmful stuff
The CDC states plainly that “the water in a hookah does not filter smoke.” WHO EMRO likewise says it is wrong to believe the smoke is purified by passing through water.
For coughing, a harsh throat and what is known about the lungs, see Why Does Hookah Make Me Cough?.
Myth 2: Nicotine-free (herbal) hookah is harmless
Herbal products contain no nicotine, but the CDC says smoke from both tobacco-based and “herbal” shisha contains carbon monoxide and other toxic agents. A 2012 study that compared tobacco-based and tobacco-free products found that toxicants such as carbon monoxide and tar were substantial with both, and that nicotine was the only one that differed significantly. The authors wrote that their findings contradict advertising that presents herbal products as a healthy alternative. Another study found high levels of metals such as lead and arsenic in some herbal products (Hammal et al., 2015).
Myth 3: It’s lighter than cigarettes
The FDA notes that hookah users may take in more carbon monoxide than cigarette smokers, because sessions are long and the volume of smoke inhaled is large. The CDC estimates that a single session exposes a user to nearly nine times the carbon monoxide and 1.7 times the nicotine of one cigarette.
For how hookah compares with cigarettes, heated tobacco and vapes, see Hookah vs Cigarettes, Heated Tobacco and Vapes.
Myth 4: I only smoke occasionally, so I won’t get hooked
Hookah tobacco contains nicotine. The CDC calls nicotine a highly addictive chemical, the FDA describes hookah as delivering the addictive drug nicotine, and WHO EMRO states that waterpipe tobacco is highly addictive.
For more on dependence and where to get help in Japan, see Is Hookah Addictive?.
Myth 5: It doesn’t affect the people around me
According to the CDC, secondhand hookah smoke contains smoke from the tobacco as well as from the heat source, such as charcoal. In a survey published by the Tokyo Metropolitan Government in March 2025, 22.2% of people who had been in the same space as someone smoking shisha said they had experiences such as feeling unwell.
For more on how hookah smoke affects the people around you, see Hookah Secondhand Smoke.
“How many cigarettes is one hookah?” How to read the numbers
You will often see hookah compared with a certain number of cigarettes. The most commonly quoted figures are:
- WHO EMRO: one bowl of unflavoured tobacco has the nicotine equivalent of 2 to 12 cigarettes.
- CDC: an hour-long session involves inhaling about 90,000 ml of smoke, 100 to 200 times the volume of a single cigarette (about 500 to 600 ml).
- Fujimi City (Saitama, Japan): a 60 to 90 minute session produces about 145 mg of carbon monoxide, roughly eight times that of one cigarette.
These figures depend heavily on how they were measured. The UK’s National Centre for Smoking Cessation and Training (NCSCT) explains that controlling for individual habits, such as breathing patterns, the size of the waterpipe and the materials used, has proven difficult in machine-smoking studies, and that each mixture has a different smoke composition. The WHO figure also refers specifically to unflavoured tobacco, which may differ from the sweet flavoured tobacco most people smoke today.
Rather than treating any single number as “safe” or “dangerous,” it is more accurate to read them as a trend: a hookah session tends to involve a large amount of smoke.
What changes the level of risk
The same hookah can carry very different levels of risk depending on how it is used. Three factors come up again and again in public health information:
- Time. A session typically lasts around an hour, according to the CDC, and the longer you smoke, the more smoke you inhale.
- Frequency. The NCSCT notes that people who use a waterpipe daily can take in nicotine equivalent to up to ten cigarettes. Occasional use and daily use are not the same.
- Ventilation. In tests by the Tokyo Metropolitan Government, carbon monoxide in a closed room reached levels high enough to cause headaches and nausea within one to two hours. Tokyo advises running extractor fans or opening doors and windows to bring the concentration down.
None of these make hookah safe, but they explain why two people who “smoked hookah last night” may have had very different exposures.
Carbon monoxide poisoning
The risk that deserves the most attention is carbon monoxide (CO) poisoning. CO comes from the charcoal and burning tobacco, and a single session lasts about an hour, according to Japan’s Consumer Affairs Agency. The agency has reported cases of hookah users losing consciousness after leaving a venue and being diagnosed with CO poisoning.
If you get a headache, feel dizzy or nauseous, stop smoking straight away, get some fresh air, and seek medical care if symptoms continue. Symptoms, first steps and when to call 119 are covered in Feeling Sick After Hookah? Nicotine vs Carbon Monoxide, and What to Do.
Infection and pregnancy
- Sharing hoses and mouthpieces. The FDA warns that bacteria living in the hose may transmit infectious diseases from person to person. WHO EMRO notes that sharing a waterpipe can spread hepatitis and herpes viruses, and possibly tuberculosis. Stanford Medicine’s tobacco prevention toolkit also lists colds and influenza among the risks.
- Pregnancy. The CDC says babies born to people who use hookah are at increased risk of respiratory diseases, and WHO EMRO notes that use or secondhand exposure can also have adverse effects during pregnancy.
For pregnancy and breastfeeding in more detail, see Hookah While Pregnant or Breastfeeding.
For smoking while taking the pill, see Hookah and Birth Control.
The rules in Japan
- Smoking is prohibited for anyone under 20 in Japan.
- Under the Health Promotion Act, the manager of a facility with a smoking room “must not allow persons under 20 years of age to enter the smoking room,” in the words of the government’s official English translation. The same rule applies to smoking lounges, and Japan’s Ministry of Health, Labour and Welfare explains that it applies even to people who do not intend to smoke, and to employees as well as customers.
- In practice, this means under-20s cannot use a hookah venue in Japan, even for nicotine-free flavors or soft drinks.
For the laws behind the 20+ rule, ID and what it means for groups and visitors, see Hookah Age Limit in Japan.
Practical ways to lower the risk
You cannot make hookah risk-free, but you can lower the risk:
- Keep sessions short and infrequent. Avoid long sessions and daily use.
- Choose a well-ventilated place. Tokyo and the Consumer Affairs Agency both urge users to check that a venue is well ventilated.
- Smoke slowly. Take breaks between puffs instead of drawing continuously.
- Skip it when you’re unwell. And stop as soon as something feels off.
- Think about hygiene. Sharing a hose or mouthpiece carries a risk of infection.
- Avoid it during pregnancy. Including secondhand exposure.
- Know the warning signs. Headache, dizziness and nausea can be signs of carbon monoxide poisoning.
Drinking too? See Hookah and Alcohol: What to Know Before Drinking While You Smoke.
FAQ
Is it okay to try hookah once?
Hookah is never risk-free. If you do try it, choose a well-ventilated venue, keep the session short and only smoke when you feel well.
Is nicotine-free hookah safe?
It avoids nicotine, but it still produces carbon monoxide and other toxicants, according to the CDC.
Is “one hookah equals X cigarettes” true?
Public agencies have published several figures, but they vary widely with how people smoke and how the figures were measured. Treat them as a sign that the amount of smoke tends to be large.
Can I bring a friend who is 19?
No. In Japan, under-20s may not enter smoking areas at all, whatever they order.
Summary
- Hookah is a tobacco product and is not harmless. Water does not filter the smoke.
- Nicotine-free hookah still produces carbon monoxide.
- “How many cigarettes” figures depend heavily on measurement conditions.
- Nicotine is addictive. In Japan, under-20s cannot use hookah venues at all.
- Keep sessions short, choose good ventilation, and stop at the first sign of feeling unwell.
For the basics, read What Is Hookah (Shisha)? A Beginner’s Guide to Trying It in Japan, and to avoid nicotine, see What Is Nicotine-Free (Herbal) Shisha?.
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; please bring photo ID (a passport is best for visitors)
References
- U.S. Food and Drug Administration, “Hookah Tobacco (Shisha or Waterpipe Tobacco)”
- Centers for Disease Control and Prevention, “Hookahs”
- WHO Regional Office for the Eastern Mediterranean, “Tobacco Free Initiative fact sheet: waterpipe tobacco smoking”
- NCSCT, “Waterpipe tobacco smoking: briefing”
- Shihadeh A, et al. Food and Chemical Toxicology, 2012
- Hammal F, et al. “‘Herbal’ but potentially hazardous,” Tobacco Control, 2015
- Stanford Medicine Tobacco Prevention Toolkit, “Hookah Crash Course”
- Japanese Law Translation, “Health Promotion Act” (official English translation)
- Ministry of Health, Labour and Welfare, passive smoking prevention site (Japanese)
- Tokyo Metropolitan Government press release, March 2025 (Japanese)
- Consumer Affairs Agency, warning on carbon monoxide poisoning from waterpipes, May 2023 (Japanese)
- Fujimi City, Saitama, on waterpipe smoking (Japanese)
