Carbon monoxide and particulates can affect a smoker’s heart health.

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Hookah tobacco is often flavored. Getty Images

Hookah smoking may seem harmless, as it’s most often done occasionally in social situations only, but smoking tobacco in water pipes can be quite damaging to your heart, a new study warns.

A report in the medical journal Circulation published March 8 finds that people who smoke from a water pipe, also known as hookah, narghile or shisha, can inhale more toxic chemicals than if they smoked a cigarette.

Each hookah smoking session lasts for about 30 or more minutes. Burning charcoal is placed on top of a bowl filled with tobacco, which is connected with a water base and hose that attaches to a mouthpiece. The tobacco often includes dried fruit, flavored tobacco and other substances so the tobacco does not dry out.

Users inhale many liters of smoke that are filled with large quantities of particulate matter. In fact, one hookah session results in more carbon monoxide exposure compared with smoking one cigarette. Hookah smoke includes other chemicals that can impair the cardiovascular system such as nicotine, volatile organic compounds (VOCs), polycyclic aromatic hydrocarbons, acrolein, lead, cadmium, and arsenic. Again, most of the toxin levels are higher in hookah than in cigarette smoke.

A growing body of evidence suggests that hookah smoking affects blood pressure and heart rate. Regular use is linked with increased coronary artery disease risk.

A study out last year found that people’s heart rates went up 16 beats per minute after 30 minutes of hookah smoking. Also, their blood pressure rose. The smoking also stiffened arteries to a degree similar to the damage that can be caused by having one cigarette.

“Hookah smoking has many of the same health risks as cigarette smoking, and hookah smoke contains several toxic chemicals known to cause lung, bladder, and oral cancers,” , deputy director for research translation from the Centers for Disease Control and Prevention’s Office on Smoking and Health, told Healthline. Because of the way a hookah is used, including the number of puffs over a longer period of time, smokers may even absorb more of these toxic chemicals than cigarette smokers.”

About 4.8 percent of high school students and 13.6 percent of adults 18 to 24 years old participate in hookah smoking.

Rates of hookah smoking among those ages 18 to 24 are more than 50 percent higher than in adults 25 to 44 years old, and nearly 200 percent higher than adults ages 45 to 64.

About 1.2 percent of middle school students smoked hookah last year, King noted.

Among adults, hookah smoking is the fifth most commonly used tobacco product behind cigarettes, cigars, e-cigarettes, and smokeless tobacco, King added.

People who use a hookah are more likely to start smoking cigarettes compared to those who have never smoked hookah, the study authors say.

“Many young people mistakenly believe that smoking tobacco from a hookah is less harmful than cigarette smoking because the tobacco is filtered through water, but there is no scientific evidence that supports that claim. However, there is evidence to suggest that hookah smoking is addictive and can lead to the use of other tobacco products such as cigarettes,” Aruni Bhatnagar, PhD, chair of the writing group for the report, said in a statement. Bhatnagar also is a professor and director of the University of Louisville Diabetes and Obesity Center in Kentucky.

Hookah tobacco is often sold in candy and fruit flavors that appeal to younger people — along with colorful packaging. The flavors and sweeteners added to hookah tobacco can cover up the taste and smell of tobacco smoke, making it more pleasing for younger people to start and continue using hookah. Most of the hookah tobacco does not display any a health warning, leading to the misperception that it is not harmful.

Hookah smoking may seem like it’s not dangerous because it may only be done occasionally. It also may be perceived as not addictive or less harmful than smoking cigarettes, Bhatnagar told Healthline.

Jaime Sidani, PhD, assistant director of the University of Pittsburgh Center for Research on Media, Technology and Health, agreed that there is a misconception that hookah smoking is harmless.

“Young people may see it as more attractive or exotic compared to traditional cigarette smoking,” she told Healthline. Hookah smoking does not seem to carry the same stigma that is attached to traditional cigarette smoking, Sidani said.

“Hookah use by young adults could be a catalyst for cigarette smoking,” Bhatnagar added.

Vaping tends to be more popular among young people, but hookah has an appeal all its own — the social factor. High school students report using hookah with friends, Sidani said. The devices are designed to be shared, she added.

Many people smoke hookah together in lounges specifically for hookah smoking. has shown that hookah lounges often have close proximity to college campuses.

“This may be particularly enticing to young people who are not yet 21 years old and cannot access alcohol-serving establishments, but can enter most hookah lounges at 18,” she explained.

“Many young people view it as socially acceptable among their peers,” Sidani added.

Social media likely plays a role in how young people perceive hookah. A study published earlier this year in Health Education & Behavior assessed nearly 300 Instagram posts and found hookah was portrayed positively in 99.6 percent of the posts.

Rates of hookah smoking among people 18 to 24 are more than 50 percent higher than in adults 25 to 44 years old, and nearly 200 percent higher than adults ages 45 to 64.

Now a new report in the journal Circulation finds that people who smoke from a water pipe, also known as hookah, narghile or shisha, can inhale more toxic chemicals than if they smoked a cigarette.