Alternative Smoked Tobacco Products

Hookahs (Water Pipes)

A hookah (also known as narghila) is a tobacco water pipe consisting of a bowl, body, water basin, and one or multiple hoses. Please click here to view more information about hookah.

Why do people use hookahs?

  • Some believe that hookah smoke is less harmful than cigarettes because it is filtered through water1.
  • College student users tend to claim that smoking hookah is an alternative to cigarettes or drinking2.
  • In addition to the chemicals and carcinogens that come from burning tobacco, hookah smoke has additional chemicals from the burning charcoal3.

Kreteks (Clove Cigarettes)

  • Kretek is a cigarette blended with tobacco and shredded clove buds4.
  • Research does not support the belief that clove cigarettes are safer than conventional cigarettes5.
  • Analyses indicate that smoke produced from clove cigarettes deliver more nicotine, tar, and carbon monoxide than conventional cigarettes5.
  • Current research indicates that clove cigarettes pose similar health risks posed by conventional cigarettes such as lung cancer and general respiratory problems6.
  • In 2009, cigarettes flavored with “fruit, candy, or clove” were banned by the Family Smoking Prevention and Tobacco Control Act7. Since then, clove filtered small cigars (no longer cigarettes) have become available8. The difference being that they are now wrapped in tobacco rather than paper.

Percentage of U.S. students who were current Kretek smokers in 20129

These rates are lower than in 200910. Current use was based on self-reported use in the past 30 days9,10.

  • Middle School – 0.5% of all students
    • 0.4% of female students
    • 0.6% of male students
  • High School – 1.0% of all students
    • 0.5% of female students
    • 1.5% of male students


  • Bidis (also spelled beedi or beedie; pronounced "bee-dees") are hand-rolled filter-less cigarettes that consist of tobacco wrapped in a tendu leaf (Diospyros mebunoxylon)11, a plant native to India and Sri Lanka.
  • Bidi users are exposed to three times the tar of a conventional cigarette12.
  • Bidis require more puffs per minute to stay lit than conventional cigarettes13. This can subject users to increased levels of carcinogens.
  • A variety of studies have found that bidi use is associated with greater likelihood of developing several oral-related problems as well as some chronic conditions11 such as:
    • Esophageal cancer14
    • Stomach cancer15
    • Lung Cancer16
  • Workers who hand-roll bidis are exposed to tobacco dust and flakes—resulting in detectable levels of biomarkers such as cotinine in workers with no tobacco habit(fix up sentence)17,18. Bidi rolling is associated with chromosomal abnormalities19. This appears to be due to tobacco dust inhalation and general tobacco exposure by workers20.

Percentage of U.S. students who were current bidi smokers in 20129

These rates are lower than in 200910. Current use was based on self-reported use in the past 30 days9,10.

  • Middle School – 0.6% of all students
    • 0.4% of female students
    • 0.7% of male students
  • High School – 0.9% of all students
    • 0.5% of female students
    • 1.3% of male students

The notion that hookah, clove cigarettes, and bidis are safe alternatives to conventional cigarettes is not supported. Research indicates that they can cause equal or greater harm than conventional cigarettes to individuals who use them.


Additional Resources:

  1. Sharma, E., Beck, K. H., & Clark, P. I., Social context of smoking hookah among college students: Scale development and validation. Journal of American College Health, 2013. 61: p. 204-211
  2. (The Bacchus Network) (2011, April 16).  Reducing hookah use:  A public health challenge for the 21st century.  Retrieved from
  3. Legacy Foundation (2013, May) Tobacco fact sheet:  Hookah.  Retrieved from
  4. Committee-on-Substance-Abuse, Hazards of Clove Cigarettes. Pediatrics, 1991. 88(2): p. 395.
  5. Malson, J.L., et al., Clove cigarette smoking: biochemical, physiological, and subjective effects. Pharmacology, Biochemistry & Behavior, 2003. 74(3): p. 739.
  6. World-Health-Organization, Tobacco: Deadly in Any Form or Disguise. 2006
  7. FDA, Candy and fruit flavored cigarettes now illegal in United States: Step is first under new tobacco law. 2009.
  8. Djarum Cigars.  2014  7/30/14]; Available from:
  9. CDC, Tobacco product use among middle and high school students - United States, 2011 and 2012. MMWR: Morbidity & Mortality Weekly Report, 2013. 62(45): p. 893-897.
  10. CDC, Tobacco Use among Middle and High School Students — United States, 2000–2009. Morbidity and Mortality Weekly Report, 2010. 59(33): p. 1063-1068.
  11. Rahman, M. and T. Fukui, Bidi smoking and health. Public Health (Nature), 2000. 114(2): p. 123.
  12. Mishra, U.C. and G.N. Shaikh, Total particulate matter in cigarette and bidi smoke. The Science Of The Total Environment, 1984. 37(2-3): p. 213-222.
  13. Pakhale, S.S., Jayant, K., Sanghvi, L.D., Chemical constituents of tobacco smoke in relation to habits prevalent in India. The Indian Journal of Chest Diseases & Allied Sciences, 1982.
  14. Sankaranarayanan, R., et al., Risk factors for cancer of the oesophagus in Kerala, India. International Journal Of Cancer. Journal International Du Cancer, 1991. 49(4): p. 485-489.
  15. Gajalakshmi, C.K. and V. Shanta, Lifestyle and risk of stomach cancer: a hospital-based case-control study. International Journal Of Epidemiology, 1996. 25(6): p. 1146-1153.
  16. Notani, P.N., et al., A study of lung cancer in relation to bidi smoking in different religious communities in Bombay. Indian Journal Of Cancer, 1977. 14(2): p. 115-121.
  17. Govekar, R.B. and R.A. Bhisey, Elevated urinary thioether excretion among bidi rollers exposed occupationally to processed tobacco. International Archives Of Occupational And Environmental Health, 1992. 64(2): p. 101-104.
  18. Bagwe, A.N. and R.A. Bhisey, Occupational exposure to tobacco and resultant genotoxicity in bidi industry workers. Mutation Research, 1993. 299(2): p. 103-109.
  19. Kashani, J.H., J.C. Reid, and T.K. Rosenberg, Levels of hopelessness in children and adolescents:  a developmental perspective. J. Consult. Clin. Psychol., 1989. 57: p. 496-99.
  20. Khanna, A., et al., Tobacco Dust Induced Genotoxicity as an Occupational Hazard in Workers of Bidi Making Cottage Industry of Central India. Toxicology International, 2014. 21(1): p. 18-23.