Carbon Monoxide Levels Among Patrons of Hookah Cafes

Background

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.

Purpose

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

Methods

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

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).

Conclusions

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.

Introduction

Little is known about the health effects or degree of toxin exposure associated with hookah smoking or how the practice compares to cigarette smoking under natural smoking conditions. Volatilized tobacco, burning charcoal, and the hose of the hookah (plastic, rubber, or leather) may all contribute to the toxin load inhaled by hookah smokers. Most of the carbon monoxide (CO) produced by smoking a hookah likely is from the charcoal used to burn tobacco,¹ resulting in high carboxyhemoglobin levels among smokers. Hookah smoke contains many of the same toxins2, 3, 4 found in cigarette smoke. However, hookah smokers may be exposed to more toxins in one smoking session than a cigarette smoker would typically be exposed to from smoking 100 cigarettes⁴ (note: this information has important limitations as shown in earlier studies4, 5). Using a small pilot sample and lab-based environment, one study⁶ found elevated CO levels for hookah users but did not find differences in exhaled CO concentrations by gender, smoking status, or session categories in this controlled environment. Further, one study⁷ reported a mean CO value of 28.7 parts per million (ppm) for hookah users after a 45-minute lab-based session, and another⁸ reported a mean CO value of 35.5 ppm in a lab-based sample.

Although the lab-based studies have provided valuable information regarding differences in hookah products, this research has been extended by employing field research methods⁹ validated in alcohol studies of bar patrons.10, 11, 12, 13 Field methods allow for event-specific analyses of risk behavior in natural smoking settings. The focus of the research was to assess the level of CO among hookah cafe patrons, using traditional bar patrons as a control group. To our knowledge, this is the first field study report on CO levels among hookah cafe patrons. Bacha et al.¹⁴ used a similar assessment in natural environments, in which they invited participants to a waterpipe café and found mean CO of 38.5 ppm for hookah smokers, an increase of 300% in CO for their sample, pre– and post–hookah session.