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In addition to poor response to medications, those who continue to smoke are observed to have reduced exercise tolerance contributing further to reduction in daily function

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Conclusion three The naturally occurring nicotine in Hookah Tobacco smoke is addictive: The fact is that most cigarette smokers are addicted to their habit, whereas the rituals associated with using a Hookah make it far less likely that the typical Hookah user is addicted to Hookah smoke, which means that they are not consuming the smoke at the same frequency as a cigarette smoker

BMJ 348 , g1151 (2014)