Alternative Smoked Tobacco Products

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Alternative Smoked Tobacco Products

Hookahs (Water Pipes)

  • Hookah is a single or multi-stemmed, often glass-based device used for smoking.
  • It is found in many areas of the world including China, India, Pakistan, the Middle East, Europe and more recently, the U.S.
  • Hookahs vary widely in shape and size, but include: a head (consisting of a ceramic bowl with a conical cap), a metal body (attached to a glass bottle partially filled with water), and a flexible tube with a mouthpiece affixed to the neck of the bottle.
  • The tobacco used is: shisha, maassel, tumbâk, jurâk.
  • They are moist, shredded tobacco mixed with sweeteners such as honey, molasses, and fruit which is placed in the head of the hookah with a heating apparatus (usually charcoal).
  • Combustion begins in the head, where the smoke then passes through the water in the body of the pipe where it is cooled and diluted before traveling through the hose where the smoker inhales it.

How Hookahs and Cigarettes Compare and Differ

  • Water pipe smoking delivers the addictive drug nicotine and is at least as toxic as cigarette smoke.13
  • Due to the mode of smoking—including frequency of puffing, depth of inhalation, and length of the smoking session—hookah smokers may absorb higher concentrations of the toxins found in cigarette smoke.12,13
  • A typical 1-hour-long hookah smoking session involves inhaling 100–200 times the volume of smoke inhaled from a single cigarette.14
  • Hookah smokers are at risk for the same kinds of diseases as are related to cigarette smoking, including oral cancer, lung cancer, stomach cancer, cancer of the esophagus, reduced lung function, and decreased fertility.15
  • Many smokers believe that the water in the hookah will filter out any harmful toxins, making it safer to smoke than cigarette. The water filtration in a hookah reduces some toxins, but does not reduce the level of tar inhaled from the smoke, which contains the most carcinogens.
  • Hookah smokers may be at greater risk than cigarette smokers, considering waterpipe smokers are exposed to greater amounts of nicotine, carbon monoxide, and other toxins.9
  • Hookah smokers often inhale much deeper, allowing the smoke to penetrate the lungs more deeply.
  • Secondhand smoke from hookahs poses a serious risk for nonsmokers, particularly because it contains smoke not only from the tobacco but also from the heat source (e.g., charcoal) used in the hookah.12,14
  • Hookah can also spread infectious diseases, such as tuberculosis, aspergillus, and heliobacter, through the sharing of the pipe or by the uncontrolled process in which the tobacco is made. 9 Photo derived from:

Hookah and Cancer

  • The charcoal used to heat tobacco in the hookah increases the health risks by producing high levels of carbon monoxide, metals, and cancer-causing chemicals.12,14
  • Even after it has passed through water, the smoke produced by a hookah contains high levels of toxic compounds, including carbon monoxide, heavy metals, and cancer-causing chemicals.14
  • Hookah tobacco and smoke contain numerous toxic substances known to cause lung, bladder, and oral cancers.12,14
  • Irritation from exposure to tobacco juices increases the risk of developing oral cancers. The irritation by tobacco juice products is likely to be greater among hookah smokers than among pipe or cigar smokers because hookah smoking is typically practiced (with or without inhalation) more often and for longer periods of time.16

Hookah and Other Health Effects…

  • Hookah tobacco and smoke contain numerous toxic substances known to cause clogged arteries and heart disease.12,14
  • As mentioned before, infectious diseases may be transmitted by sharing a hookah.13
  • Babies born to women who smoked one or more water pipes a day during pregnancy have lower birth weights than babies born to nonsmokers by at least 3 ½ ounces. They are also at increased risk for respiratory diseases.15

Kreteks (Clove Cigarettes)

  • Kretek is the Indonesian name for a clove cigarette.
    • Most clove cigarettes are imported from Indonesia and are similar to American cigarettes in many ways.
  • Clove cigarettes contain a mixture of shredded clove buds and tobacco, which produces a distinct, pungent smell.
  • Clove cigarette smoke contains more nicotine, tar, and carbon monoxide than conventional cigarettes.
    • Clove smokers are at greater risk for acquiring an acute lung injury, as well as developing abnormal lung functioning than non-smokers.7,8 Photo derived from:
  • Kretek smoking is associated with an increased risk for acute lung injury (i.e., lung damage that can include a range of characteristics such as decreased oxygen, fluid in the lungs, leakage from capillaries, and inflammation), especially among susceptible individuals with asthma or respiratory infections.17
  • Regular kretek smokers have 13 to 20 times the risk for abnormal lung function (e.g., airflow obstruction or reduced oxygen absorption) compared with nonsmokers.18

Percentage of U.S. students who were current kretek smokers in 200919

  • 1.2% of all middle school students
  • 0.7% of female middle school students
  • 1.6% of male middle school students
  • 2.4% of all high school students
  • 1.9% of female high school students
  • 2.9% of male high school students

Bidis (Flavored Cigarettes)

  • Bidis (pronounced "bee-dees") are thin, hand-rolled, filter-less cigarettes.
  • They consist with flavored or unflavored tobacco wrapped in a tendu or temburini leaf.
  • They come in a wide variety of flavors (e.g., vanilla, strawberry, mango).
  • Bidi smoke contains higher concentrations of nicotine, tar, and carbon monoxide than conventional cigarettes sold in the United States.
  • Smokers must puff bidis with greater frequency than conventional cigarettes.1,2
  • Indian research studies indicate that bidi smokers are at greater risk for developing oral, lung, stomach, and esophagus cancer, as well as coronary heart disease, acute myocardial infarction, and chronic bronchitis than non-smokers.2,3,4 Photo derived from
  • Smoke from a bidi contains 3 to 5 times the amount of nicotine as a regular cigarette and places users at risk for nicotine addiction.21
  • Bidi smoking is associated with a more than threefold increased risk for coronary heart disease and acute myocardial infarction (heart attack).20,23
  • Bidi smoking is associated with emphysema and a nearly fourfold increased risk for chronic bronchitis.20,22

Percentage of U.S. students who were current bidi smokers in 200913

  • 1.6% of all middle school students
  • 1.2% of female middle school students
  • 2.0% of male middle school students
  • 2.4% of all high school students
  • 2.1% of female high school students
  • 2.7% of male high school students

Overall, there are a vast majority of products that can be used alternatively for tobacco; Hookahs, Kreteks, and Bidis. Hookahs are basically a single or multi-stemmed, often glass based device used for smoking, Kreteks are clove cigarettes that contain shredded clove buds and tobacco, and Bidis are flavored cigarettes that are thin, hand-rolled, filter-less cigarettes. Despite there being many tobacco alternatives, these alternatives have the same, if not, more harmful effects then cigarettes alone. Many of them cause lung cancer, heart disease, and other infections (due to sharing alternative tobacco products (e.g. Hookah)). Alternative tobacco products are not a good alternative for tobacco and can cause detrimental effects on your body.

Last updated: March 19, 2014

1 Watson, C., Polzin, G., Calafat, A., & Ashley, D. (2003). Determination of tar, nicotine, and carbon monoxide yields in the smoke of bidi cigarettes. Nicotine & Tobacco Research, 5, 747-753.
2 Rahman, M. & Fukui, T. (2000). Bidi smoking and health. Public Health, 114, 123-127.
3 Nayak, K., Gett, S., Sharda, D. & Misra, S. (1989). Treadmill exercise testing in asymptomatic chronic smokers to detect latent coronary heart disease. Indian Heart Journal, 41, 62-65.
4 Gupta, P., Murti, P. & Bhonsle, R. (1996). Epidemiology of cancer by tobacco products and the significance of TSNA. Critical Reviews in Toxicology, 26, 183-198.
5 Centers for Disease Control and Prevention (2005). Tobacco use, access, and exposure of tobacco in media among middle and high school students - United States, 2004. Morbidity & Mortality Weekly Report, 54 (12), p. 298.
6 Malson, J., Lee, E., Murty, R., Moolchan, E., & Pickworth, W. (2003). Clove cigarette smoking: Biochemical, physiological, and subjective effects. Pharmacology, Biochemistry, and Behavior, 73, 739-745.
7 Mangunnegoro, H. & Sutoyo, D. (1996). Environmental and occupational lung diseases in Indonesia. Respirology, 1, 85-93.
8 Anonymous. (1988). Evaluation of the health hazard of clove cigarettes. Council on Scientific Affairs. Journal of the American Medical Association, 260, 3641-3644.
9 Knishkowy, R. & Amitai, Y. (2005). Water-pipe (Narghile) smoking: An emerging health risk behavior. Pediatrics, 116, e113-e119.
Click here for link to full-text article.
10 Hatsukami, D. K. & Zeller, M. (2004). Tobacco harm reduction: The need for research to inform policy. Retrieved from, April 2007.
11 Hamilton, W. L., diStefano-Norton, G., Ouellette, T. K., Rhodes, W. M., Kling, R., & Connolly, G. N. (2004). Smokers' responses to advertisements for regular and light cigarettes and potential reduced-exposure tobacco products. Nicotine & Tobacco Research, 6 (Suppl. 3), S353-S362.

12American Lung Association. An Emerging Deadly Trend: Waterpipe Tobacco Use Exit Notification. (PDF–222 KB) Washington: American Lung Association, 2007

13Akl EA, Gaddam S, Gunukula SK, Honeine R, Jaoude PA, Irani J. The Effects of Waterpipe Tobacco Smoking on Health Outcomes: A Systematic Review Exit Notification. International Journal of Epidemiology 2010;39:834–857

14World Health Organization. Tobacco Regulation Advisory Note. Water Pipe Tobacco Smoking: Health Effects, Research Needs and Recommended Actions by Regulators Exit Notification. (PDF–550 KB) Geneva: World Health Organization, Tobacco Free Initiative, 2005

15Nuwayhid, I, Yamout, B., Ghassan, and Kambria, M. Narghile (Hubble-Bubble) Smoking, Low Birth Weight and Other Pregnancy Outcomes Exit Notification. American Journal of Epidemiology 1998;148:375–83

16El-Hakim Ibrahim E., Uthman Mirghani AE. Squamous Cell Carcinoma and Keratoacanthoma of the Lower Lips associated with "Goza" and "Shisha" Smoking. International Journal of Dermatology 1999;38:108-10

17World Health Organization. Tobacco: Deadly in Any Form or Disguise Exit Notification.
(PDF–144 KB) Geneva: World Health Organization, 2006