What Are These Things?

Hookah pens. Hookah sticks. E-cigs. Vapes. Maybe you’ve heard of one or all of these terms. Despite the variety, they all refer to the same fundamental thing (so don’t get confused when the terms are used interchangeably).

A hookah pen is an electronic device that delivers nicotine as a vapor to the user. In contrast to a traditional cigarette, there is nothing to light, and therefore no smoke. For some users, this is actually a downside, and manufacturers have begun to create faux-smoke out of the vapor that helps mimic the “feel” of a traditional cigarette.

A typical device is made up of 3 components: a liquid e-hookah cartridge, a replaceable battery, and a heating element (also known as an atomizer). The cartridge (like the battery) is replaceable and contains a flavored liquid ready to be vaporized. While in some cases, this liquid may not contain nicotine, most cartridges do. The cartridge also includes the mouthpiece of the device.

E-cigarettes, hookah sticks, vapes, etc. are all marketed as a safer alternative to smoking. The logic is that by avoiding tobacco and its smoke, users are no longer exposed to the laundry list of carcinogens and toxins found in typical cigarette smoke. While there are scientific review articles supporting this line of thinking [1], the WHO cautions that the safety of these devices “has not [yet] been scientifically demonstrated” [2].

e-cig-components
A look at the inside of an e-cigarette.

What Is Nicotine?

Vapes, hookah pens, and e-cigs all provide the same drug as tobacco cigarettes: nicotine. Nicotine is a stimulant drug that makes its way to the brain within 10-20 seconds [3], creating the characteristic “head rush” associated with cigarette smoking. This rush is dose-dependent, so a deep inhalation creates a bigger rush. Vapor-delivered nicotine works in the same way, allowing vapor cigarettes to mimic the effects that make smoking so addictive.

So Is This the Same as a Hookah?

While the names “hookah” and “hookah pen” sound very similar, they are in fact very much different. Hookah involves using a special type of tobacco (called shisha) and passing its vapor or smoke (depending on the type of hookah) through a water basin before inhalation. While both hookahs and hookah pens are usually flavored, the hookah pen only contains the nicotine, while hookahs use tobacco outright.

Hookahs have become increasingly popular in recent years, especially among teenagers and college-age young adults. Many people mistakenly believe that hookahs are a safer alternative to smoking. This is likely due to the fruity flavors and misconception that hookah is “just water”. In reality, the American Lung Association cautions that hookahs (referred to as “waterpipes” in their report) “are not a safe alternative to smoking cigarettes” [4]. In fact, a typical hour-long hookah session involves 200 puffs, compared to 20 puffs for a regular cigarette [5]. This, combined with other factors such as depth of inhalation, suggest that hookah smokers may in fact absorb more harmful toxins than cigarette smokers [6].

This all comes in contrast to the hookah pen/stick, e-cigarettes, and vapes, as they circumvent the toxin issue by never using tobacco in the first place. As discussed above, there is still insufficient data to determine whether this mitigates the health risk, but at the very least, the underlying processes between hookahs and hookah pens are significantly different.

A Word on Secondhand Smoke

Cigarette smoking is known to cause numerous cancers, lung disease, and other ailments in smokers, but the dangers of secondhand smoke cannot be overstated. According to the American Cancer Society, secondhand smoke is responsible for 46,000 heart-related deaths in current nonsmokers, 150,000-300,000 lower respiratory tract infections in children under 18 months of age, and $10 billion in extra costs of medical care, illness, and death per year in the U.S. alone [7].

Secondhand smoke is an undoubted killer, and curbing it is a major public health issue. It is perhaps an underrated benefit of vapor cigarettes that they do not produce secondhand smoke. In fact, many e-cigarettes have an orange LED at the end just to simulate the look of a burning cigarette, since there is no actual burning going on in these electronic devices.

How Do Hookah Pens Differ From E-Cigarettes?

At the beginning of the article, we said that there wasn’t much difference between a hookah pen and an e-cig. At their core, both are ultimately the same thing. But a quick look at hookah pens in comparison to e-cigarettes shows a distinct difference in how each product is marketed.

Hookah pens and hookah sticks tend to be brightly colored, sometimes with attractive designs and glittering sparkles. This is in direct contrast to the look of e-cigarettes, which tend to have relatively dull designs intended to mimic the look of a regular cigarette. It should come as no surprise then, that hookah pens are gaining most of their popularity among younger demographics, while e-cigarettes target former smokers who are looking for a more socially acceptable and perhaps healthier alternative to their old habit.

Hookah Pen vs. E-Cigarette
Compare and Contrast: Hookah pens (left) vs. E-Cigarette (right)

Hookah Pens and the Law

These devices have been the center of some significant legal controversy. In 2010, the FDA argued that e-cigarettes (and by extension, related products) should be regulated as “drug delivery devices”. However, in December of that year, an appellate court ruled against the FDA unanimously, indicating that vapor cigarettes should be regulated as tobacco products (even though they contain no tobacco), as they are aimed at current smokers and are not sold as a therapeutic option for people interested in quitting.

Because there is not much federal regulation surrounding hookah pens and similar devices, state-level governments have begun to enact their own laws, particularly with respect to regulating sales to minors. At the time of this writing, Colorado, Kentucky, Maryland, Minnesota, New Hampshire, New Jersey, New York, Tennessee, Utah, and Wisconsin have laws regulating vapor cigarette sales.

Public Health Ramifications

Although they are not marketed as such, there is a potential use for hookah sticks, etc. as smoking cessation aids. In much the same way that a nicotine replacement patch can be used to wean a person off of cigarettes, vapes may also be tapered down. More research in this area is required, and at this time there is no evidence to support the assertion that e-cigarettes, vapes, hookah pens or any other electronic nicotine delivery system is beneficial for smoking cessation.

As mentioned above, hookah pens and similar devices hold the public health benefit of eliminating secondhand smoke. Secondhand smoke causes an estimated $10 billion of medical care, illness, and death-related expenses in the U.S. each year. Again, while research is required to support any claims, there is the potential for a significant public health benefit simply by switching current smokers to a vapor-based device.

One area of serious concern—particularly with hookah pens—is the possibility of sales to minors. The law tends to move slowly, and many states have not yet enacted regulations on the sale of hookah pens. Given the bright colors and appealing flavors, it is no surprise that hookah pens have gained rapid popularity among the younger demographics. While there have been many regulations put in place to curtail the marketing of cigarettes to children, there is need for similar action on the matter of electronic hookah pens.

The Bottom Line

The title of this article asks if hookah pens are safe, and unfortunately the answer to that is a resounding… “maybe”. Logic and initial data seem to support the idea that the biggest health risks in cigarettes are the tars, toxins, and chemicals that are byproducts of burning tobacco. By eliminating these, there is a possibility of lowering the risk of cancer (most notably lung cancer) and other ailments, but whether that risk is the same as a nonsmoker remains to be seen.

Many electronic cigarettes/vapes/hookah sticks/etc are imported from China and under limited regulation. The combination of these factors creates a quality control issue. Much of the reasoning behind the safety benefit of vaporized nicotine lies with the purity of the nicotine itself. If other chemicals or additives find their way into the liquid nicotine cartridge, the risks could be even greater than that of tobacco cigarettes.

For this reason, the safest option is still not to smoke at all. If you have never smoked, do not start. If you are a smoker and want to quit, talk to your doctor about therapies and support groups that may be of assistance. If, however, you aren’t ready to quit but are looking for an alternative to tobacco, purchasing a hookah pen or similar device from a U.S.-based retailer might be your best option.

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17 COMMENTS

  1. they have not been around long enough to have sufficient testing to see the outcome of the chemicals that are still entering your body

    basically everyone that’s using them are being their guinea pigs for the people that might use them in the next 15 years

  2. just because there are no tar toxins or chemicals from tobacco in it does not make it safe ,there are still chemicals and things in them that nobody knows how it effects the body yet ,because e-ciggs hookahs have not been around long enough to see the long term results done to you

    they are safer then normal cigarets and shisha ,but its still putting yourself at risk IMO

    • Well its a good thing it is better than a cigerette… But that people who smoke cogarette daily cannot addict to thisbe hookah

  3. My daughter wants one of these cause she smokes some and knows I am against it so she says these are safer. I am still undecided about what to do???

  4. im 15 and just bought one cause all the kids at school are doing it and i dont know if i should because im so addictaed?????

  5. Since there is no combustion within the pen, there is no tar. When you light a cigarette, you are burning the components of the cigarette, which creates tar. This is what is most harmful. Besides, these use a lot less nicotine than regular cigarettes

  6. You also have to consider that if you get the liquid with no nicotine in, you aren’t getting the tobacco or nicotine that makes shisha and cigarette so harmful. It’s almost just flavored liquid at that point. Guaranteed we don’t know any effects to that. But I can definitely say you don’t get any buzz or feeling from an e-hookah with the no nicotine liquids. In fact most of the random people I’ve met(which would be 4 just counting today, small but still)that have one like myself only use the no nicotine liquids. But I can see why it needs to be made shady. Because there is so much money made off cigarettes, so how could you possibly endorse a safer if not safe alternative, with no tar, nicotine, or tobacco? And contrary to popular belief most of the e-hookah liquids have a no nicotine version too. So the idea that it’s not likely for one to get an e-hookah and the no nicotine liquid because it’s hard to find so they will settle with the nicotine is false.

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