Date of Award

Fall 12-21-2018

Degree Type


Degree Name

Master of Public Health (MPH)


Public Health

First Advisor

Dr. Christina Fuller

Second Advisor

Dr. Matt Hayat

Third Advisor

Dr. Roby Greenwald



This research is an environmental exposure study examining indoor levels of carbon monoxide and black carbon in Metropolitan Atlanta smoking establishments, hookah establishments, and non-smoking venues. Recently, there has been an increase in the use of shisha or “hookahs” in the U.S. Hookahs are water pipes that are used to smoke specially manufactured tobacco that comes in different flavors. The legal age for smoking hookah is 18 years; however, children of any age may be permitted into a hookah lounge/restaurant depending upon the particular city’s ordinances and many U.S. hookah establishments are classified as “family dining.” It is a common misconception, amongst hookah smokers, that the practice of hookah is less harmful than smoking cigarettes. Hookahs, like cigarettes, produce environmental tobacco smoke (ETS). ETS poses a tremendous threat to indoor air quality, contains chemicals and particles that are detrimental to one’s health, and is extremely dangerous to those who inhale it. Two components of ETS are carbon monoxide (CO) and black carbon (BC). CO exposure may cause headaches, dizziness, disorientation, nausea, fatigue, angina, impaired vision, reduced brain function, and even death. BC may cause respiratory, cardiovascular, pulmonary, gastrointestinal, renal, and dermatologic problems; the most significant endpoint is cancer. Currently, there are no specifically defined standards or regulations for BC under the Indoor Air Quality Guidelines, and to date, there are no indoor air quality regulations for CO, except those pertaining to occupational safety. However, smoking establishments may be exempt from Indoor Air Quality Guidelines for carbon monoxide levels for various reasons (WHO, 2003).


The focus of this study was to compare and contrast the levels of CO and BC exposure in cigarette smoking, hookah and non-smoking venues. The results may provide information to refine future standards or regulations for BC and CO.


Preliminary data was collected during an air sampling study utilizing the following air quality instrumentation: the MicroAeth AE51 and the Q-Trak Indoor Air Quality Monitor 7565. Three specific types of service venues made up the sampling unit: venues that permit cigarette smoking only, venues that permit hookah smoking only, and venues that do not permit smoking of any kind. A convenience sample of six locations from the Atlanta Metropolitan Statistical Area based upon accessibility to GSU were selected. For categorical variables, frequency distributions were used. For continuous variables, an appropriate measure of central tendency and corresponding measure of dispersion was used. Continuous variables were examined for normality and a quantile plot was used. The unit for CO is ppm (parts per million) and the unit for BC is ng/mg3. For each variable, appropriate summary statistics were calculated. The median and interquartile range was reported. The primary comparison was assessing the distribution of each pollutant across the venue types (Hookah, Smoking, Non-smoking). Non-parametric statistical tests were applied. The Kruskal-Wallis one-way layout was applied with post hoc multiple comparisons. Spearman correlation coefficients were used to quantify association between the variables. The level of significance in this study was set at α=0.05. Data was analyzed using Microsoft Excel and SAS.


The study indicates that inhaling ETS from both hookah and smoking establishments may have potential dangers, because the concentration levels of both BC and CO are significantly higher in hookah and smoking establishments versus non-smoking establishments (p≤0.05). The study also shows that while BC levels in smoking establishments are significantly higher than in hookah establishments, CO levels are significantly higher in hookah establishments than in smoking establishments (p≤0.05).


The results of this study do not support the hypothesis that the mean level of CO and BC concentrations in industry venues that permit cigarette smoking is equal to the mean level of CO and BC concentrations in hookah establishments. Additionally, the mean level of CO and BC concentrations in industry venues that permit cigarette smoking and venues that permit hookah smoking do not equal the mean level of CO and BC concentrations in non-smoking establishments. The results of this study advance scientific knowledge on the factors influencing tobacco smoke pollution and inform public health advocates and decision makers on smoking policy needs. Additional monitoring is necessary to draw more divisive conclusions on BC and CO levels in hookah venues. Currently, local, city, and state laws regulate smoke-free policies, and there is a vast need for standardization across these governing regulations. The Food and Drug Administration (FDA) regulates tobacco policies, while indoor air quality is regulated and governed by each individual state’s health department. Therefore, it will be necessary for these agencies to collaborate to monitor and assess compliance.