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Clearing the stem.
Hookah is officially classified by WHO, the CDC, and ACOG as a tobacco product whose use during pregnancy is discouraged the same way cigarettes are. Observational studies from Iran, Egypt, and Lebanon link hookah smoking with lower birth weight, more frequent preterm birth, and lower Apgar scores.
This is an association, not a proven cause: every study on the topic is observational — it captures a co-occurrence of hookah smoking and pregnancy outcomes, but cannot rule out the influence of concurrent cigarette smoking, socioeconomic conditions, or nutrition. Randomized trials that could prove causation are not possible for ethical reasons. The authors of systematic reviews themselves rate the quality of evidence for most outcomes as low or very low.
This is the most studied outcome, though the size of the effect varies noticeably between countries.
The spread is notable: the Iranian cohorts show a difference of roughly 100–140 g, while the Cairo study shows about 400 g. The likely reason is difference in design (interview-based versus prospective cohorts), sample size, and the share of women who also smoked cigarettes.
A 2010 systematic review (24 studies, GRADE-rated) gives a pooled odds ratio for low birth weight of 2.12 (95% CI 1.08–4.18) — statistically significant. A 2025 systematic review and meta-analysis (191 studies, 807,174 participants, 24 countries) also finds a significant association, but rates this outcome as low-quality evidence.
A common claim states that hookah smoking in the first trimester nearly triples the risk of low birth weight, and that such babies have lower Apgar scores and more lung problems. The figure traces back to a single source — a 1998 Lebanese study by Nuwayhid and colleagues (106 narghile smokers, 277 cigarette smokers, 512 non-smokers). Among women who started smoking hookah specifically in the first trimester, the odds ratio for low birth weight was indeed 2.62 — but with a 95% CI of 0.90–7.66, which crosses 1: the result did not reach statistical significance, and with the same probability there may be no real association at all. The 1998 authors themselves called the finding merely "noticeable," not proven. Popular retellings — for example, a qualitative study in BMC Public Health, 2015 — present the figure as an established fact, though the original source does not claim this.
Isfahan, Iran (512 women, 256 hookah smokers): preterm birth occurred in 15.23% of smokers versus 7.18% of non-smokers (p=0.008); a 5-minute Apgar score below 4 in 13.67% versus 4.29% (p=0.013); pre-eclampsia in 22.65% versus 10.93% (p<0.001); placental abruption in 12.5% versus 5.85% (p<0.001). The association with stillbirth was not significant (5.07% versus 1.17%, p=0.14).
In Cairo, the highest adjusted risk of preterm birth and/or low birth weight was among women who combined hookah and cigarettes (odds ratio 40.06; 95% CI 5.30–302.59), and 9.55 (95% CI 2.17–42.00) for hookah-only smokers; such wide confidence intervals signal estimates from a small sample rather than a precise risk figure. Apgar data are limited to these two studies and do not appear in the systematic reviews found.
Iranian authors point to carbon monoxide, aromatic hydrocarbons, and volatile aldehydes crossing the placenta, plus the vasoconstrictive effect of nicotine on uterine blood vessels, which may raise the risk of fetal hypoxia, as the likely mechanism: a single 45-minute session, by their estimate, delivers more than 40 times the smoke volume of one cigarette.
A German study of smoke composition (BfR) found significant amounts of nickel, cadmium, lead, and chromium in hookah tobacco and coal, and 6.2 times more benzene in mainstream smoke than in cigarette smoke; this is an analysis of smoke composition, not of pregnant women, and it did not test a direct link to pregnancy outcomes. An experiment on rats showed a significant association with low birth weight and neonatal mortality (p<0.01) — translating this result to humans is limited by species differences.
ACOG (Committee Opinion No. 807, 2020) lists the perinatal risks of tobacco — fetal growth restriction, placenta previa and abruption, low birth weight, increased perinatal mortality — as grounds for recommending tobacco cessation in any form, noting a rise in alternative forms alongside cigarettes, including hookah. The CDC states: hookah smoking during pregnancy can affect a baby's health — babies born to people who smoke hookah daily may weigh less at birth and face an increased risk of respiratory disease. WHO's Advisory Note on waterpipe tobacco smoking (2nd edition, TobReg, 2015) lists low birth weight among the documented problems of hookah smoking; the exact wording of a recommendation for pregnant women could not be confirmed from the full document.
The UK's NHS does not mention hookah at all on its official page about pregnancy and quitting smoking — only cigarettes. A warning about shisha for a UK audience came from the charity British Heart Foundation, not the NHS: shisha smoke still contains nicotine, carbon monoxide, and other harmful chemicals, and shisha is not safer than cigarettes.
A survey of pregnant women in Cairo (200 participants, third trimester): 69% had a smoking husband, and among the non-smoking women themselves, 38% reported exposure to secondhand smoke during the current pregnancy — significantly more often when the husband smoked indoors (p<0.001). Women who were actually exposed were less likely to agree that it was harmful to their health or their baby's than women in other groups — though all groups overall agreed that secondhand smoke was harmful to the newborn.
Surveys in Jordan (2012 and 2017–2018, 6,726 mother-infant pairs): a mother's cigarette smoking was associated with a significantly lower likelihood of continued breastfeeding (adjusted OR 0.51; 95% CI 0.30–0.87). For hookah, smoked by 5.4% of mothers in the sample, no statistically significant association with stopping breastfeeding was found — but this is not proof of safety: the share of hookah-smoking mothers may have been too small for statistical power, and the authors do not discuss this question separately.
No direct studies of pregnancy outcomes from smoking tobacco-free ("herbal") or nicotine-free hookah mixes were found — not one. There are only studies of the composition and emissions of such smoke outside the context of pregnancy: heavy metal content (lead, chromium, nickel, arsenic) and aromatic hydrocarbons in individual samples are comparable to or higher than in tobacco mixes, and combustion byproducts, according to the authors, are equivalent to or exceed those of tobacco shisha — but this cannot be extended to pregnancy outcomes; the question remains unanswered.
The overall picture has been built from studies with low or very low quality of evidence for most outcomes, as reflected in the wide confidence intervals. Missing are Apgar data beyond these two studies, testing of the proposed mechanisms in pregnant women themselves, and randomized trials, which are impossible here for ethical reasons.
Does smoking in the first trimester nearly triple the risk to the baby?
No: the figure traces back to a 1998 Lebanese study where an odds ratio of 2.62 did not reach statistical significance (95% CI 0.90–7.66) — the authors themselves called the finding merely "noticeable."
Does hookah lower a baby's birth weight?
Studies from Iran and Egypt document such an association, but the effect size differs between countries — from 100–140 g to about 400 g — and the quality of evidence is rated low.
What do WHO, the CDC, and ACOG say?
All three classify hookah as a tobacco product requiring cessation during pregnancy on par with cigarettes; the CDC specifically notes the risk of lower birth weight and respiratory disease in children.
Are tobacco-free and nicotine-free mixes safe during pregnancy?
There are no direct studies on pregnant women — only data on the toxic composition of their smoke outside the context of pregnancy, so no conclusion about safety can be drawn.
Can you smoke hookah while breastfeeding?
A Jordanian study of 6,726 mother-infant pairs found no statistically significant link between hookah (unlike cigarettes) and stopping breastfeeding, but the sample of hookah-smoking mothers was small.
Related topics on the site: "How Hookah Affects Health: What Science Says," "Secondhand Hookah Smoke: What Non-Smokers Inhale," "Safety: Carbon Monoxide, Ventilation, How Long to Smoke," "Top 10 Hookah Myths," and "How to Minimize the Risks of Smoking Hookah."
Medical organizations recommend discussing smoking in any form during pregnancy and breastfeeding with the doctor managing the pregnancy.