Carbon Monoxide Levels Among Patrons of Hookah Cafes


      Individuals who use a hookah (water pipe) as a method of tobacco smoking are exposed to high levels of carbon monoxide (CO). Assessing hookah use in one of the venues of its use (hookah bars) will aid the understanding of the toxins and exposure for the user. In Florida, smoking is prohibited in public places under the Florida Clean Indoor Act but permitted in establishments that have less than 10% gross revenue from food.


      To assess the CO level of hookah cafe patrons, using traditional bar patrons as a comparison.


      After IRB approval, a nighttime field study of patrons (aged >18 years) exiting hookah cafes and traditional bars in 2009 was conducted, using sidewalk locations immediately outside these establishments in a campus community. As hookah cafes and bars are typically entered and exited in groups, every other group of people exiting the establishment was approached. For comparison purposes, the sample collected was similar in number, 173 hookah cafe and 198 traditional bar participants.


      Results from analysis conducted in 2010 indicate that patrons of hookah cafes had significantly higher CO levels (mean=30.8 parts per million [ppm]) compared to patrons of traditional bars (mean=8.9 ppm). Respondents who indicate no cigarette use in the past month but had visited a hookah cafe still demonstrated significantly higher CO values (mean=28.5 ppm) compared to those exiting traditional bars (mean=8.0 ppm). Current cigarette smokers also produced significantly more CO if exiting a hookah cafe (mean=34.7 ppm) compared to a traditional bar (mean=13.3 ppm).


      CO levels are higher for patrons of hookah cafes, for both current and non-cigarette smokers. Although users report that they perceive hookah to be less harmful than cigarettes, the greater CO exposure for hookah users that was observed in this study is not consistent with that perception.
      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'


      Subscribe to American Journal of Preventive Medicine
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect


        • Monzer B.
        • Sepetdjian E.
        • Saliba N.
        • Shihadeh A.
        Charcoal emissions as a source of CO and carcinogenic PAH in mainstream narghile waterpipe smoke.
        Food Chem Toxicol. 2008; 46: 2991-2995
        • Astora K.
        Hooked on hookah?.
        TRDRP Newsletter. 2005; 7 (13): 8-9
        • Shihadeh A.
        Investigation of mainstream smoke aerosol of the argileh water pipe.
        Food Chem Toxicol. 2003; 41: 143-152
        • Shihadeh A.
        • Saleh R.
        Polycyclic aromatic hydrocarbons, carbon monoxide, “tar”, and nicotine in the mainstream smoke aerosol of the narghile water pipe.
        Food Chem Toxicol. 2005; 43: 655-661
        • Shihadeh A.
        • Azar S.
        A closed-loop control “playback” smoking machine for generating mainstream smoke aerosols.
        J Aerosol Med. 2006; 19: 137-147
        • El-Nachef W.N.
        • Hammond S.K.
        Exhaled carbon monoxide with waterpipe use in U.S. students.
        JAMA. 2008; 299: 36-38
        • Eissenberg T.
        • Shihadeh A.
        Waterpipe tobacco and cigarette smoking: direct comparison of toxicant exposure.
        Am J Prev Med. 2009; 37: 518-523
        • Maziak W.
        • Rastam S.
        • Ibrahim I.
        • Ward K.D.
        • Shihadeh A.
        • Eissenberg T.
        CO exposure, puff topography, and subjective effects in waterpipe tobacco smokers.
        Nicotine Tob Res. 2009; 11: 806-811
        • Clapp J.D.
        • Holmes M.R.
        • Reed M.B.
        • Shillington A.M.
        • Freisthler B.
        • Lange J.E.
        Measuring college students' alcohol consumption in natural drinking environments—field methodologies for bars and parties.
        Eval Rev. 2007; 31: 469-489
        • Thombs D.L.
        • Dodd V.
        • Pokorny S.B.
        • et al.
        Drink specials and the intoxication levels of patrons exiting college bars.
        Am J Health Behav. 2008; 32: 411-419
        • Thombs D.L.
        • O'Mara R.
        • Dodd V.J.
        • et al.
        A field study of bar-sponsored drink specials and their associations with patron intoxication.
        J Stud Alcohol Drugs. 2009; 70: 206-214
        • Thombs D.L.
        • O'Mara R.
        • Dodd V.J.
        • et al.
        Event-specific analyses of poly-drug abuse and concomitant risk behavior in a college bar district in Florida.
        J Am College Health. 2009; 57: 575-585
        • Thombs D.L.
        • O'Mara R.J.
        • Tsukamoto M.
        • et al.
        Event-level analyses of energy drink consumption and alcohol intoxication in bar patrons.
        Addict Behav. 2010; 35: 325-330
        • Bacha Z.A.
        • Salameh P.
        • Waked M.
        Saliva cotinine and exhaled carbon monoxide levels in natural environment waterpipe smokers.
        Inhal Toxicol. 2007; 19: 771-777
      1. Florida Legislature. Florida Clean Indoor Air Act (FCIAA). In: Florida Legislature, ed. Chapter 386, Part II. 1985.

        • Bedfont Scientific Ltd
        Smokerlyzer piCO+ Operating Manual4.
        Bedfont Scientific Ltd, Rochester, Kent, United Kingdom2007
        • Middleton E.T.
        • Morice A.H.
        Breath carbon monoxide as an indication of smoking habit.
        Chest. 2000; 117: 758-763
        • Cavus U.Y.
        • Rehber Z.H.
        • Ozeke O.
        • Ilkay E.
        Carbon monoxide poisoning associated with narghile use.
        Emerg Med J. 2010; 27: 406
        • Lim B.L.
        • Lim G.H.
        • Seow E.
        Case of carbon monoxide poisoning after smoking shisha.
        Int J Emerg Med. 2009; 2: 121-122
        • Uyanik B.
        • Arslan E.D.
        • Akay H.
        • Ercelik E.
        • Tez M.
        Narghile (hookah) smoking and carboxyhemoglobin levels.
        J Emerg Med. 2009; ([Epub ahead of print])
        • Jabbour S.
        • El-Roueihab Z.
        • Sibai A.M.
        Nargileh (water-pipe) smoking and incident coronary heart disease: a case–control study.
        Ann Epidemiol. 2003; 13: 570
        • Akl E.A.
        • Gaddam S.
        • Gunukula S.K.
        • Honeine R.
        • Jaoude P.A.
        • Irani J.
        The effects of waterpipe tobacco smoking on health outcomes: a systematic review.
        Int J Epidemiol. 2010; 39: 834-857
        • Eissenberg T.
        • Ward K.D.
        • Smith-Simone S.
        • Maziak W.
        Waterpipe tobacco smoking on a U.S. college campus: prevalence and correlates.
        J Adolesc Health. 2008; 42: 526-529
        • Primack B.A.
        • Sidani J.
        • Agarwal A.A.
        • Shadel W.G.
        • Donny E.C.
        • Eissenberg T.E.
        Prevalence of and associations with waterpipe tobacco smoking among U.S. university students.
        Ann Behav Med. 2008; 36: 81-86
        • Smith S.Y.
        • Curbow B.
        • Stillman F.A.
        Harm perception of nicotine products in college freshmen.
        Nicotine Tob Res. 2007; 9: 977-982
        • Smith-Simone S.
        • Maziak W.
        • Ward K.D.
        • Eissenberg T.
        Waterpipe tobacco smoking: knowledge, attitudes, beliefs, and behavior in two U.S. samples.
        Nicotine Tob Res. 2008; 10: 393-398
        • Asfar T.
        • Ward K.D.
        • Eissenberg T.
        • Maziak W.
        Comparison of patterns of use, beliefs, and attitudes related to waterpipe between beginning and established smokers.
        BMC Public Health. 2005; 5: 19