Welcome back to our weekly diabetes advice column, Ask D'Mine, hosted by veteran type 1 and diabetes author Wil Dubois in New Mexico. Here, you can ask all the potentially awkward practical questions you may not know who to ask.

With the prevalence of new marijuana laws around the country and the popularity of vaping, we've had an influx of questions related to this topic. Today, Wil addresses one re: smoking shisha and diabetes.

{Got your own questions? Email us at AskDMine@diabetesmine.com}

 

Jessica, type 3 from California, asks: Can smoking shisha in a hookah cause the blood sugar to increase? My husband’s blood sugar was never extremely high until he started doing that. Thanks for your reply.

Wil@Ask D’Mine answers: Surprisingly, it just might. And there are three factors in play that could be the, uh... smoking gun. Sorry. I couldn’t resist. But before I dig into those, let’s cover some hookah basics for readers who may not be familiar with this ancient eastern apparatus.

A hookah is a type of water pipe used for smoking flavored tobacco (and sometimes opium or cannabis). Unlike a western tobacco pipe—which is lit with a match and kept burning by the action of puffing on the pipe—a hookah has a built-in source of combustion in the form of charcoal briquettes placed above the tobacco bowl. Why? I suspect the answer is: The tobacco that’s smoked in a hookah differs from the tobacco we usually see in Western pipes. Called shisha, it’s mix of tobacco, molasses, and fruit. Keeping dried fruit lit takes more than the occasional match. 

Hookahs are often communal, with many smoking tubes coming off the water pipe like some sort of ornamental octopus. Hookahs can be used solo or in a group, at home or in hookah lounges.

As with any kind of smoking, the white coat crowd will wail and gnash their un-tobacco-stained teeth, and tell you the sky is falling. They worry about infectious diseases, because, after all, you’re smoking a germ incubator. They worry about toxic chemical exposure from the flavorings. They worry that, like all smoking, sucking on a hookah will raise your blood pressure and your heart rate. They worry that smoking causes inflammation that can lead to type 2 diabetes. And that you’ll be at increased risk for cancer.

All true.

But what about blood sugar?

The science on that is somewhat limited. But I did find one study that showed a much stronger association between metabolic syndrome, diabetes, obesity, and dyslipidemia in hookah smokers than in cigarette smokers, suggesting that cigarettes are “better” for your health than hookahs. And no, Philip Morris and R.J. Reynolds didn’t fund the study.

At least I don’t think they did… 

But I digress. Although we seem to be lacking in direct literature specifically on the subject of blood sugar levels (as opposed to the more general increased risk of diabetes from smoking), I did discover some interesting data on something called “hookah sickness,” which is basically a form of carbon monoxide poisoning. This is a problem unique to hookahs among tobacco-smoking options, and is caused by the burning charcoal briquettes that heat the flavored tobacco in the water pipe. Some pretty cool research showed that while nicotine levels for all smoking products are about the same, folks using traditional hookahs exhale 9 to 10 times more carbon monoxide compared to cigs or electronically heated hookahs.

Now the interesting part is how carbon monoxide poisoning works, on an anatomic level—whether the source be a hookah or a hose from the tailpipe of a car.  Apparently, carbon monoxide binds to hemoglobin to form carboxyhemoglobin, which reduces oxygen to the brain. So I have to wonder, if carbon monoxide binds to hemoglobin, is it a far stretch to think that the carbon monoxide in hookah smoke might have a blood sugar effect? I don’t know. We know there is a relationship between hemoglobin and glucose. A before and after fingerstick would be an interesting experiment.

Speaking of nicotine, which I mentioned in passing just a moment ago, did you know that nicotine triggers the release of glucose from the liver? It does. In a slam-dunk study, California Polytechnic scientist Xiao-Chuan Liu, Ph.D., was able to isolate nicotine as the root cause of smoking’s long-recognized sugar-raising effect. His research shows that nicotine can bump A1C by a whopping 34%. 

For perspective, if your A1C were, say 7.5, increasing it by 34% turns it into a 10-plus. 

Ouch. 

Meanwhile, discussions on the effects of hookah smoking and blood sugar come up quite frequently in internet discussion boards, with quite a bit of argument as to whether hookahs raise blood sugar, and if they do, how would they do so? Beyond the nicotine and the carbon monoxide we already discussed, I came across a really interesting idea at the community board Hookah Lounge. There, a guest poster called MrMister theorized that perhaps the glucose in the fruit and molasses in the shisha might be the culprit. That’s an interesting thought.

Let’s think about that. Assuming the hookah smoker inhaled rather than puffed, and most do, as the water bowl cools the smoke, anything carried in the smoke will travel from the lungs into the bloodstream. Quickly. Clearly, shisha smoke contains vaporized glucose. But does vaporized glucose still act like sugar? Based on how glycerol vapor acts, I think we can be pretty confident that it would; but whether there’s enough glucose in the smoke to make a detectable difference, I can’t say. Like anything else having to do with carbs, I suppose it would depend on how much you smoked, and how sensitive to sugar you are. Still, most PWDs will see a bump in their blood sugar if they eat even a tiny bit of fruit without a bolus. Something to ponder while you puff.

Meanwhile, huffing sugar might be an interesting alternative to glucagon for some small startup to investigate. Hey, if you can inhale powdered insulin and lower your blood sugar, why not inhale powdered glucose and raise it? But please don’t try this at home with the left-over powdered sugar from holiday baking.

Back to hookahs and blood sugar: For your husband, the proof was in the hookah bowl. He started huffing and his sugar went high. Looking at the science, there are at least three possible causes, and perhaps it’s a combination of all three. So, yeah, I can see that, for him, at least, the smoking is raising his sugar. 

So now what? Does he need to quit? Not necessarily, although given all the other health effects of smoking, quitting might be a sensible New Year’s resolution. Still, I’m not in the business of telling others how to live their lives. I will say this, however: Anything that you do—either good for you or bad for you—that raises your blood sugar demands that you make a change. That change could be to quit, or that change could be to increase your diabetes medications.

Either way. 

But leaving your blood sugar “extremely high” isn’t an option.

 

This is not a medical advice column. We are PWDs freely and openly sharing the wisdom of our collected experiences — our been-there-done-that knowledge from the trenches. But we are not MDs, RNs, NPs, PAs, CDEs, or partridges in pear trees. Bottom line: we are only a small part of your total prescription. You still need the professional advice, treatment, and care of a licensed medical professional.