Smoking: Hookah - NYC Health

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Carbon Monoxide Poisoning From Smoking Hookah

The NYC Poison Control Center has been receiving reports of carbon monoxide poisoning from smoking hookah.

Hookah pipes typically use burning charcoal, which releases carbon monoxide.

Carbon monoxide, by itself, is a colorless and odorless gas.

The risk of carbon monoxide poisoning can vary, based on the size and ventilation of the space where hookah is smoked, the amount of charcoal burning in that space and the amount of time spent in that space.

Common symptoms of mild carbon monoxide poisoning include headaches, sleepiness, fatigue, confusion and irritability. Dangerous symptoms of carbon monoxide poisoning include nausea, vomiting, irregular heartbeat and impaired vision or coordination.

If you have these symptoms after being around indoor hookah smoke, seek medical attention immediately.

At very high blood levels, carbon monoxide poisoning can result in seizures, brain damage or death.

Health care providers should report possible cases of carbon monoxide poisoning associated with hookah use to the NYC Poison Control Center at 212-POISONS (212-764-7667).

Hookah

Young people (ages 18 to 20) in NYC are three times more likely to smoke a hookah than those who are 21 and older. This may be because they underestimate the health risks of smoking hookah and are unaware that they are inhaling harmful smoke when they visit a hookah-serving establishment.

In 2018, 0.8% of middle school students and 5.6% of high school students smoked hookah. While youth who smoke cigarettes are most likely to smoke hookah, the rate of hookah use among youth who never smoked cigarettes has increased in the past ten years. This is particularly troubling because some studies suggest that young people who smoke hookah may be more likely to try cigarettes.

Dangers of Hookah Smoke

A hookah, or water pipe, uses burning charcoal to heat shisha, a flavored blend of herbal substances. Tobacco is a popular and common ingredient in shisha, but some shisha is tobacco-free. No type of shisha — with or without tobacco — is a healthy alternative to cigarettes.

People smoking hookah and those around them are exposed to toxic chemicals in hookah smoke. These toxic chemicals come from two different sources: the charcoal that is burned to heat the shisha and the shisha itself. Many of these chemicals (PDF), such as carbon monoxide, tar and formaldehyde, are also found in cigarette smoke. When shisha contains tobacco, the smoke also contains nicotine, which is addictive. Water does not effectively filter out unhealthy chemicals from hookah smoke.

The chemicals in hookah smoke can increase your risk of:

Heart attack

Decreased lung function

Respiratory symptoms

Cancer

Premature death (for people with heart and lung disease)

Unlike smoking cigarettes, smoking hookah can also cause carbon monoxide poisoning.

Laws About Commercial Hookah Smoking

Strict NYC laws about hookah went into effect in 2018. Retail stores and other establishments are banned from selling or serving shisha to people younger than 21. Flavored hookah containing tobacco may not be sold within NYC except by tobacco bars registered with the health department.

People younger than 21 are not permitted to enter hookah-serving establishments.

It is now required for all hookah-serving establishments to have permits from the Health Department and the Fire Department. They may not serve shisha which contains tobacco and must display warning signs about the health risks of hookah smoke. No new permit applications are being accepted. Existing permit holders may now renew their Non-Tobacco Hookah Establishment Permit online. Only establishments with a current permit from the Health Department may allow hookah smoking inside their premises.

Warning Signs

The Health Department provides warning signs to licensed non-tobacco hookah establishments. The signs must be clearly visible and posted at each entrance and in each room or area, indoor and outdoor, where smoking hookah is allowed.

Hookah Warning Signs FAQ (PDF)

Other languages: Español | العربية

Age Restriction for Customers of Non-Tobacco Hookah Establishments

Establishments are required to check the identification of all customers who reasonably appear to be younger than 30 years old, to ensure they are at least 21 years old.

Valid forms of identification include a valid driver’s license or other photo ID issued by the government or an educational institution.

Sanitizing Hookah Pipes

The Smoke-Free Air Act requires licensed establishments to:

Clean and sanitize all hookah pipes before use.

Provide an individually wrapped mouthpiece tip to each customer.

Fire Safety

The Fire Department requires non-tobacco hookah establishments to:

Maintain portable fire extinguishers in all spaces where lighted coals are prepared, handled or used.

Prepare and store charcoal according to specific standards.

Ensure that surfaces are noncombustible, and decorations are flame resistant.

Maintain carbon monoxide alarms in every room where coals are prepared or used.

Laws and Rules

§ 17-513.5 Non-tobacco hookah establishments

§ 10-18 – 10-23 Requirements to operate a non-tobacco hookah establishment

§ 310-03 Hookah Establishments

Additional Resources

Report a Smoking Violation in NYC

Hookah Fact Sheet: Centers for Disease Control and Prevention (CDC)

More Information

Smoke-Free Air Laws

NYC Quits

Information on Smoking, Tobacco and E-cigarette Use for Clinicians