Hookah addiction may be stronger than cigarette addiction

12 September 2018 - 14:04 By Kamran Siddiqi
Because hookah is often smoked with friends and family, getting over the addiction may be hard for smokers.
Because hookah is often smoked with friends and family, getting over the addiction may be hard for smokers.
Image: 123RF / Cppzoe

Smoking hookah (hookah or hubbly bubbly) is very popular, particularly among young people. And despite what many people believe, it is highly addictive. In fact, a drug commonly prescribed to help people quit smoking cigarettes doesn’t seem to work for hookah smokers, our latest study shows.

Given that hookah is often smoked with friends and family, its addiction may be more than just physical. This strong social element to the addiction may be the reason the smoking cessation drug, varenicline, which is effective for cigarette smokers, doesn’t have the same effect on daily hookah smokers.

Traditionally smoked by older men in the Middle East and South Asia, hookah has now gained popularity around the globe. Hookah cafes and bars have opened in most cities in Europe and the US in recent years. Flavoured brands, such as fruit hookah, have become particularly popular with young people who are attracted to hookah’s romantic allure – it is seen as fashionable and exotic.


In a hookah (also known as a waterpipe or hookah), tobacco is burned using charcoal. The smoke passes through a water-filled bowl and leaves through a hose. By inhaling at one end of the hose, a vacuum is produced that makes smoke pass through the water to the smoker.

There are two common misconceptions about hookah smoking. The first is that it is less harmful than cigarettes as the smoke is believed to be “cleansed” while passing through water. The second is that it is less addictive than cigarettes.

Both assertions are wrong. Hookah smokers inhale large quantities of harmful particles and are at risk of the same diseases as cigarette smokers, including a variety of cancers. In fact, during a single session of hookah, one can inhale several times more nicotine, carbon monoxide and cancer-causing chemicals than a single cigarette.

Between hookah smoking sessions, smokers show cravings and withdrawal symptoms just like cigarette smokers, even with infrequent use.


There has been very little research done on ways to help hookah smokers quit successfully. Approaches, such as counselling and medication, are usually successful in getting cigarette smokers to quit, but have shown little promise with hookah smokers, so far.

For our study, we recruited 500 hookah smokers in Pakistan. For 12 weeks, half the research participants were treated with the drug varenicline, the other half with a placebo. Both groups were also given advice on changing behaviour to help them address some of the psychological aspects of addiction.

Our results showed that varenicline was not more effective than a placebo. This study does not necessarily show that the drug did not work in hookah smokers, but, despite the willingness of participants to quit, only a minority made a serious attempt at quitting.

The study also demonstrated that hookah smokers that took part in the study were highly dependent and many smoked cigarettes as well, reducing the effect of the drug.

There are many layers to addiction, neurological and psychological, and one of the things we found in this study is that the social aspect of smoking hookah played a significant role in its appeal. Almost 90% of the study participants smoked hookah with their family or friends.


Strong tobacco control policies are needed to break the social norms of hookah smoking alongside conventional medication and counselling.

The way tobacco is sold and bought for hookah consumption means that standard packaging with graphic health warnings either doesn’t exist or doesn’t have an impact.

Inconsistent policies for tobacco price and taxation mean that smoking hookah is still fairly cheap for most people. Hookah smokers may have a better chance of quitting if hookah smoking is less affordable and not served in cafes, bars and restaurants.

An approach, similar to that taken against cigarette smoking, to raise awareness of the risks, particularly with young people, and control its use in public spaces would be a step forward, alongside traditional quitting approaches.

• Kamran Siddiqi is professor in Global Public Health at the University of York.

• This article is republished from The Conversation under a Creative Commons license. Read the original article.

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