BMJ Case Reports 2013; doi:10.1136/bcr-2013-009526

Syncope associated with water pipe smoking

  1. Suha Turkmen
  1. Department of Emergency Medicine, Medicine Faculty, Karadeniz Technical University, Trabzon, Turkey
  1. Correspondence to Dr Yunus Karaca, yunuskaraca52{at}


The water pipe (narghile) in particular is widely used in the Arabian Peninsula and the Turkish world, and has also recently become an increasingly popular way of consuming tobacco in Europe. Contrary to popular belief, it contains more tar, carbon monoxide (CO) and toxic gases than cigarettes. This report describes a patient presenting to the emergency department with syncope as a result of water pipe use, with tests revealing toxically high CO levels.


The waterpipe, also known as the narghile, shisha, hookah or hubble bubble, has for long been a widely employed way of consuming tobacco in India and among Arabs and Turks on the Arabian peninsula and on the Mediterranean.1 Carbon monoxide (CO) is a tasteless, odourless gas with a binding affinity for haemoglobin 200 times greater than that of oxygen. Findings of CO intoxication are frequently seen in metabolically active organs such as the heart and brain.2 We describe a case presenting to the emergency department with syncope after water pipe smoking with test results revealing CO intoxication.

Case presentation

A 20-year-old woman was brought to the emergency department with fainting symptoms. Her general condition was fair-to-good. She was lucid but agitated. Her Glasgow Coma Score was 15, systolic blood pressure was 70/40 mm Hg, pulse 96/min and respiration rate 26/min. Anamnesis revealed that she had experienced syncope while smoking a water pipe and that consciousness had returned with fluid resuscitation given in the ambulance. ECG was normal. Blood glucose level was 94 mg/dl, and no abnormality was determined in electrolyte levels. A brain CT was taken and no abnormality was determined. CO intoxication was suspected and blood gas analysis was performed. FCOHb (fraction of carboxyhaemoglobin) was determined at 31.1% (normal value 0.5–2%). The patient was started on 10 l/min O2 support and hydration. FCOHb levels at the second and eighth hours were 21% and 1%, respectively. The patient's health condition stabilised at the 12th hour. Her vital findings were normal, and she was discharged from the emergency department.

Outcome and follow-up

The patient's general condition stabilised at 12th hour. Her vital findings were normal, and she was discharged from the emergency department.


The water pipe is a traditional way of smoking widely used on the Arabian peninsula and the Mediterranean. Water pipe use varies by form and culture, but it generally consists of a clay bowl in which the tobacco is placed and burned, a metal body, a water bowl made of glass, a plastic or leather pipe through which the smoke passes and a mouthpiece (figure 1). Studies report that it is being increasingly used for socialisation among university students in particular.3 Water pipe use is widespread, because it is generally thought to be less harmful than cigarettes owing to its pleasant taste and smell. The fact is, however, that the water in the water pipe only retains a small part of the toxic substances. Since water pipe smoking is a lengthy process and since users receive a greater volume of smoke with every intake, water pipe smokers are more exposed to CO than cigarette smokers. In addition, the water pipe contains more CO particles since coal is used to burn the tobacco. Furthermore, since water pipe smoking generally takes place in closed environments, smokers are also continuously exposed to emitted particles.4 It takes an average of 1 h to smoke a water pipe, and exposure to CO is approximately seven times greater compared with cigarettes.5

Figure 1

A water pipe.

CO intoxication is a significant cause of child and adult deaths across the world. Since CO is tasteless and odourless, victims may be unaware of its presence. Patients generally present to the emergency department with non-specific symptoms, and it may therefore be difficult for health professionals to diagnose. Delayed diagnosis may result in delayed treatment and the development of various problems.6

Learning points

  • Water pipe is increasingly used in European countries.

  • Water pipe smokers are more exposed to CO and tar than cigarette smokers.

  • Water pipe smoking can cause syncope owing to CO poisoning.

  • The emergency physician must be aware of the conditions associated with water pipe smoking.


  • Competing interests None.

  • Provenance and peer review Not commissioned; externally peer reviewed.


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