Hookah smokers are familiar with the fuzzy, lightheaded feeling brought on by sucking on a keg of flavored tobacco for extended periods of time. Those symptoms, along with headaches and nausea, are often referred to as "hookah sickness" and typically pass shortly after finishing a smoking session.
Earlier this month a smoker in Australia was sent to the hospital with symptoms that sounded like a case of hookah sickness, albeit a rather extreme one. When she arrived at the hospital, however, doctors said she was suffering from carbon monoxide poisoning.
While it's not news that smoking hookah—or just smoking in general—elevates the amount of carbon monoxide in your blood, it's safe to say hookah benders don't normally put people in the ER.
TheSydney Morning Herald reported that the 20-year-old was no newbie and smoked "regularly." She had also, their report says, been smoking for "up to an hour at a time." She clearly took in more than her share of smoke, but it's not obvious that she got there by doing anything wildly irresponsible. An hour spent smoking hookah is pretty normal. Even if someone carried on for two hours, it probably wouldn't attract more than an eyebrow raise and the vague suggestion that a little fresh air might be a good idea.
But this case transcended the normal effects of hookah sickness. After being hospitalized, the unnamed woman's condition worsened and she began experiencing heart-attack-like symptoms, according to Dr. Louis Wang, who treated her.
"She didn't have chest pains, but the ECG changes suggested that not enough oxygen was being supplied to her muscle in an area of her heart," Dr. Wang wrote in the Medical Journal of Australia. In the paper, "Severe carbon monoxide poisoning from waterpipe smoking: a public health concern," Wang and his coauthors indicate that they believe this was "the first Australian report of severe carbon monoxide poisoning caused by waterpipe use."
Wang said the unnamed woman was suffering from "horrific" levels of carbon monoxide. "It was 25 percent, when normal is about 1.5 percent, although really you shouldn't have any," he told Herald reporter Amy Corderoy.
Hookah.org attributes hookah sickness to too much nicotine. "Nicotine overdose comes with a handful of nasty symptoms," their article says. It lists headaches, dizziness, and light sensitivity, along with "a feeling of pressure in the chest." The article instructs the reader to "take a break before you step beyond the event horizon and get KO'd." There's no mention of carbon monoxide.
Personally, I've enjoyed the occasional hour-long (or more) hookah session and attributed the occasional chest tightness, headaches, and nausea to too much nicotine. When I first started smoking, more experienced smokers said that as long as I was using "natural coals," and kept the place ventilated, I'd be fine, and that any lingering symptoms were most likely from the nicotine.
"Hookah delivers fairly high doses of nicotine but very high doses of carbon monoxide," Dr. Kenneth D. Ward told VICE in an email. Ward is the director of the Division of Social and Behavioral Sciences at the University of Memphis School of Public Health. He has studied the culture around hookah, as well as the health effects, and written about both extensively.
To put it in even clearer terms: "'Hookah sickness' is carbon monoxide intoxication," Ward wrote, although he also pointed out that nicotine isn't blameless. "Some of these symptoms, like headache and nausea, occur with nicotine overdose as well," he wrote, adding, "I've experienced that myself smoking big cigars.
"Symptoms of 'hookah sickness' can begin at around 20 parts per million of carbon monoxide, so it's not surprising that so many users seem to experience it."
In Ward's recent published work on the topic, titled "Change in carbon monoxide exposure among waterpipe bar patrons," he and his colleagues tested the carbon monoxide levels of college students before and after smoking in a hookah bar. They found that on average, their "expired carbon monoxide levels," showed a terrifying 800 percent increase.
Carbon monoxide poisoning does more than make you feel sick, or, in very large concentrations, dead. Having high carbon monoxide concentrations in your blood can cause confusion and delirium. From time to time, stories of haunted houses are chalked up to hallucinations brought on by poor ventilation that can cause high levels of carbon monoxide.
Improving ventilation while you smoke hookah, however, isn't likely to help, according to Ward. "Since most of the carbon monoxide exposure in hookah users comes from the mainstream smoke rather than sidestream, I wouldn't expect that improving ventilation would reduce exposure very much," he told VICE.
Nonfatal cases of serious poisoning from carbon monoxide can involve total paralysis, followed by neurological impairment, followed by an agonizingly slow recovery over the course of months. One famous case study from 1972 followed a patient through a brutal, 84-day recovery period that involved seizures.
Meanwhile, hookah tobacco comes in delicious flavors. So it's still got that going for it, assuming you can get past all the carbon monoxide.
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