Key Points
Background: Why This Research Matters
What Is Shisha and How Is It Smoked?
How This Review Was Conducted
Shisha Smoking Around the World
Who Smokes Shisha? Age and Gender Patterns
Why People Choose Shisha: 15 Reasons
Common Misconceptions: Is Shisha Safer Than Cigarettes?
Shisha vs. Cigarettes: A Head-to-Head Comparison
How Shisha Affects the Body: Key Findings
Effects on Pregnancy and Newborns
Cancer Risks Linked to Shisha Smoking
Genetic and Cellular Damage
What These Findings Mean for Patients
What This Review Couldn't Prove
Recommendations for Patients and Families
Frequently Asked Questions
Source Information

Key Points

A single shisha session can deliver 1.7 times the nicotine, nearly 4 times more carbon monoxide, and 802 mg of tar compared to one cigarette.
Water does not filter out harmful chemicals; shisha smoke contains carcinogens and extra toxins from burning charcoal.
Shisha use in pregnancy is linked to lower birth weight, nearly triple the risk in the first trimester, and higher odds of low-birth-weight infants.
The review linked shisha smoking to esophageal, pancreatic, lung, and prostate cancers, plus heart rhythm changes, high blood sugar, and abnormal blood fats.
Shisha smokers are about 1.6 to 2 times more likely to have high blood pressure, high blood sugar, high blood fats, and abdominal obesity.

Background: Why This Research Matters

Tobacco is a preventable cause of illness and death across the world, and low- and middle-income countries are the hardest hit. The statistics are staggering: tobacco use causes about 5 million deaths per year worldwide, and it is currently the second leading cause of death globally, responsible for the deaths of one in ten adults. Even more sobering is the fact that half of all people who smoke today will die prematurely from a smoking-related disease.

The global picture is expected to get worse before it gets better. Researchers project that tobacco-attributable deaths will decline by only 9% between 2002 and 2030 in high-income countries, but in low- and middle-income countries, deaths are projected to double from 3.4 million to 6.8 million during the same period.

Enter shisha—a practice dating back at least 400 years that has recently exploded in popularity worldwide. Public health officials now consider shisha smoking a "global threat" and have given it the status of an epidemic. This is especially concerning because tobacco smoke contains over 4,800 different chemicals, out of which 69 are known carcinogens (cancer-causing agents) and many others promote tumor growth.

The purpose of this review, conducted by researchers at Dow Medical College and Dow University of Health Sciences in Karachi, Pakistan, was to examine all available evidence on the epidemiological variations and health effects of shisha smoking—and to equip smokers with the facts they need to make informed decisions.

What Is Shisha and How Is It Smoked?

Shisha goes by many names depending on where you are in the world. In Egypt, Saudi Arabia, and Pakistan, it's called "water pipe," "bory," or "gaza." In Jordan, Lebanon, and Syria, it's known as "narghile," "nargile," or "arghile." In the Indian subcontinent, it's called "hookah." You might also hear it referred to as "hubble bubble."

Whatever the name, the basic mechanism is the same: tobacco smoke passes through water before being inhaled. There is also regional variation in the shape, size, and appearance of the device, as well as in the type of tobacco smoked. In this review, the terms "shisha" and "hookah" refer specifically to this water-filtered method of tobacco smoking.

Important: The fact that smoke passes through water is central to one of the most dangerous misconceptions about shisha—that the water filters out harmful chemicals. As you'll see in this article, the evidence proves otherwise.

How This Review Was Conducted

The research team conducted a systematic literature review with a clear objective: to focus on epidemiological variations and the harmful effects of shisha smoking. They searched two major medical databases—PubMed and Google Scholar—using the terms "shisha," "water pipe," "narghile," and "hookah."

The search results give a sense of how much research exists on this topic:

The term "shisha" turned up 91 articles published between 1994 and 2012
"Narghile" found 94 articles from 1981 to 2013
"Hookah" unearthed 146 articles from 1982 to 2013
"Water pipe" brought up 186 articles from 1986 to 2013

All original articles, case reports, and reviews written in English were included if they addressed the epidemiology or harmful effects of shisha. Articles that didn't fit the purpose and objective of the review were excluded. The final analysis provides a qualitative overview of the global evidence.

Shisha Smoking Around the World

The prevalence of shisha smoking is rising rapidly across the globe, and the numbers from this review paint a concerning picture.

In the United States

Shisha use is peaking in the United States, climbing to 40% prevalence from 2005 to 2008. A study of two American universities found that 27.8% of students were lifetime hookah users. At the University of San Diego, 24.5% of surveyed students reported smoking shisha. Another large study reported that more than one-third (40.3%) of the entire sample had ever smoked tobacco from a shisha at some point.

According to researcher Maziak W, shisha smoking continues to spread worldwide and may represent "the second global epidemic since that of cigarette," with prevalence ranging from 6% to 39% depending on the population studied. At Wayne University, one analysis found 10% of students smoked shisha, while another study evaluated the prevalence at 26%. Among 3,010 New Jersey high school students, 9.7% reported shisha use, and a separate study found that 15% of students had used shisha at least once in their lifetime.

In Pakistan

Very few studies have assessed shisha prevalence in Pakistan, but those that exist reveal high rates of use. A study of medical and dental students in Karachi found that 22.7% were shisha smokers. At Aga Khan University, the prevalence was a striking 53.6%. Surveys at the Institute of Business Administration, Preston University, and Karachi University found a 49% prevalence of current smokers—broken down as 3.3% smoking daily, 7.1% smoking one to two times per week, and 38.6% smoking occasionally at social gatherings.

A cross-sectional study conducted in four large Pakistani cities disclosed a 61% prevalence of shisha smokers, most of whom smoked shisha occasionally. In a small semi-urban community in Karachi, 19% of tobacco smokers were shisha users.

Around the Globe

The worldwide data shows just how widespread shisha use has become:

Lebanon: In a 2005 global youth tobacco survey of 13- to 15-year-olds, a staggering 59.8% had smoked shisha at least once in the past month, compared to only 10% who smoked cigarettes.
Saudi Arabia: Studies across three different colleges found a 12.6% prevalence of shisha users.
Malaysia: Research in two rural schools and a university revealed shisha prevalence of 19% and 20%.
Beirut: A study of adolescents aged 13-20 found that 60% had smoked shisha at least once in their lifetime.
Syria: Among university students, 62.6% of males and 29.8% of females were regular shisha smokers.
Egypt: A study of 1,652 secondary school students found a 53.9% prevalence, with 30.3% of males and 8.5% of females smoking shisha.
Jordan: Hookah users at San Diego cafes and Jordanian universities showed prevalence rates of 24.4% and higher, respectively.

Who Smokes Shisha? Age and Gender Patterns

The review reveals consistent patterns in who smokes shisha. In the United States, a study of two large universities found shisha smokers are mostly males between the ages of 15 and 25. Saudi Arabia shows a similar picture: 63.8% of students start smoking shisha at ages 16-18, with males dominating. In Syria, the average age of starting the habit is 19.2 years for males and 21.7 years for females.

Pakistan follows the same trend, with males being the dominant users. One study reported 53.6% male prevalence with a mean age of 21 years. Another confirmed male dominance in shisha smokers with the same average age range. Studies across the Middle East also show male predominance, with similar findings in Egypt and Qualyobia (a region in Egypt).

Interestingly, Jordan is the exception—there, more females smoke shisha compared to males. At three Jordanian universities, 53 out of 63 shisha smokers (about 63%) were female, and at San Diego hookah cafes, 24.5% of female hookah users smoked shisha compared to 24.2% of males.

Why People Choose Shisha: 15 Reasons

The researchers identified 15 distinct reasons that help explain the surging popularity of shisha smoking. Understanding these motivations is critical for designing effective public health interventions:

Global tourism and migration flows: Tourists return from Egypt, Tunisia, and other regions with a hookah in their suitcase, and hookah lounges now exist throughout the West.
A new hassle-free lighting system: New easy-to-light charcoal makes shisha preparation simpler than ever.
Relative acceptance by non-smokers: Notable smoke irritants are filtered out, making it more socially tolerable.
Unexpected backlash effect of anti-tobacco campaigns: Some smokers view shisha as safer than cigarette smoking as a direct result of anti-smoking messaging that focuses on cigarettes.
Filtration of some noxious substances: Some carcinogens may be filtered out by the water, giving false reassurance.
A "light" dependence: Many users see shisha as easy to quit compared to cigarettes.
The influence of television: Egyptian movies have featured hookah smokers for decades, normalizing the practice.
The rise of individualism in modern societies: People seek new forms of sociability and self-expression.
Conviviality: Shisha is a "social" smoking experience—sharing the hose, talking, and spending time together.
Powerful symbolism: Shisha carries associations of dreams, art, "mysticism," and the "peace pipe."
A cross-generational, social, and cultural melting pot: Shisha is a shared practice across social, sexual, religious, and generational lines.
Flavors: "Tobamel" (mu'assel) is a flavored tobacco (or tobacco-free) mixture based on honey and molasses, available in many appealing flavors.
The cultural status of honey: Honey has cultural and religious significance (referenced in the Koran and The Bees), adding to the appeal.
A highly sensory experience: All five senses are permanently stimulated during a shisha session.
"Rebellion" values: Shisha smoking carries an aura of rebellion for young people.

Common Misconceptions: Is Shisha Safer Than Cigarettes?

Attitudes and beliefs about tobacco are the single main factor affecting people's behavior toward shisha use, yet very few studies have investigated these beliefs. What the research does show is alarming: even in developed countries, marketing promotes the fallacy that shisha is less hazardous than cigarettes, and this misconception is the main driving force behind its popularity.

Study after study confirms how widespread this belief is:

In the United States, 32% of university students believed shisha is less harmful than cigarettes.
In Pakistan, 60% of a university population considered cigarettes more harmful than shisha.
In Egypt, 49.7% of secondary school students believed shisha is less harmful, and 21% of 206 male shisha smokers specifically chose shisha because they believed it was safer.
In Jordan, 58.3% to 89.06% of shisha users across different studies held this misconception.

Here's the reality: research has shown that shisha smoking carries three additional health risks beyond those of cigarette smoking. First, because shisha is smoked over coal, the smoke contains extra harmful toxins. Second, a shisha smoker inhales up to 200 times more smoke in a single session compared to a cigarette smoker. Third, shisha is linked to higher rates of secondhand smoke exposure due to its high social acceptance.

As for the famous water filtration myth—it's simply false. Making air bubbles pass through water doesn't change their content. Volatile carcinogens and other particles in tobacco smoke stay within the air bubbles during their passage through water, so the water does not make shisha any less harmful than cigarettes.

Shisha vs. Cigarettes: A Head-to-Head Comparison

The researchers compared the smoke content of a single shisha session to that of a single cigarette. The shisha regimen studied consisted of 171 puffs, each with a volume of 0.53 liters and a duration of 2.6 seconds, with a 17-second interval between puffs. The session used 10 grams of mo'assel tobacco paste with 1.5 quick-lighting charcoal disks on the narghile head.

Here's what that single shisha session delivered:

2.94 mg of nicotine
802 mg of tar
145 mg of carbon monoxide (CO)
Greater quantities of chrysene, phenanthrene, and fluoranthrene compared to a single cigarette

The number of puffs and their volume from shisha use is about 10 times higher than a cigarette, and shisha smoke contains higher concentrations of metals. The burning temperature for shisha is about 900°C (1,652°F) compared to 450°C (842°F) for a cigarette.

While the peak concentration of nicotine is similar in cigarette and shisha smoke, the much longer duration of a shisha session results in considerably greater total nicotine exposure. Using a pharmacokinetic model, researchers calculated the nicotine AUC (a measure of total nicotine exposure over time) as 243 ng/ml-min for a cigarette versus 418 ng/ml-min for shisha. In other words, shisha smokers were exposed to 1.7 times the nicotine dose of cigarette smokers in a single session.

How Shisha Affects the Body: Key Findings

The review uncovered evidence linking shisha smoking to widespread damage across multiple body systems.

Cardiovascular Effects: The Heart Under Stress

Shisha smoking takes a significant toll on the cardiovascular system. Just 45 minutes after shisha use, heart rates increase significantly. Many studies report a measurable increase in both systolic and diastolic blood pressure and heart rate after a shisha session.

One acute effect is dysfunction in the autonomic regulation of cardiac cycles, seen as a reduction in heart rate variability—a known marker of cardiovascular risk. Reduced heart rate variability is associated with oxidative stress (cellular damage caused by free radicals) and increases in heart rate and blood pressure.

Shisha smoking also disrupts cholesterol levels. One study (Numair KA) found that shisha smokers had significantly lower levels of HDL (the "good" cholesterol) and ApoA (a protein that helps remove cholesterol from the blood) compared to non-smokers. Meanwhile, LDL-cholesterol (the "bad" cholesterol), ApoB (a protein linked to heart disease), and triglycerides (blood fats) were significantly higher in smokers.

Oxidative Stress and Blood Damage

A single shisha smoking session measurably increases oxidation injury—the cellular damage linked to aging, heart disease, and cancer. One study (Wolfram RM) found significant increases in three markers of oxidative stress:

8-epi-PGF2 alpha (p=0.003)
MDA (malondialdehyde, a marker of oxidative damage, p=0.001)
11-DH-TXB2 (a marker of platelet activation, p=0.0003)

Daily smoking induces persistent, long-lasting oxidation injury. In a study conducted in Saudi Arabia, total antioxidant capacity and vitamin C levels were both lower in shisha smokers than in non-smokers, meaning their bodies were less equipped to fight off cellular damage.

Shisha also activates platelets—the blood cells responsible for clotting—which raises the risk of dangerous blood clots.

Carbon Monoxide Poisoning: A Hidden Danger

Carbon monoxide (CO) is one of the most dangerous components of shisha smoke. CO binds to hemoglobin in red blood cells much more strongly than oxygen does, effectively starving the body of oxygen. The findings here are genuinely alarming:

Mean CO-hemoglobin (COHb) levels increase by 4 times in the first 5 minutes of shisha smoking compared to an entire cigarette.
A single session of shisha produces 4 to 5 times more CO than smoking a cigarette.
Breath CO levels in shisha smokers measure 40-70 ppm, resulting in 8-12% of blood being non-functional (unable to carry oxygen).
In heavy cigarette tobacco smokers, CO of 30-40 ppm means approximately 5-7% of blood is not functioning—shisha is far worse.
One serve of hookah smoking elevates mean CO values by almost eight times higher than cigarette smoking.

Nicotine and Respiratory Effects

In one detailed study (Eissenberg T), researchers tracked plasma nicotine levels in shisha smokers over a 45-minute session:

Before smoking: 2.0 ± 0.2 ng/ml
At 5 minutes: 6.1 ± 1.1 ng/ml
At 15 minutes: 6.4 ± 0.8 ng/ml
At 30 minutes: 7.9 ± 1.0 ng/ml
At 45 minutes: 8.5 ± 1.0 ng/ml

These increases were highly statistically significant (t(30) > 3.6; P < 0.001). The nicotine levels from waterpipe tobacco smoking were significantly higher than cigarette smoking at the 45-minute mark (t(30)=4.3; P < 0.001). Respiratory rate also increases by up to 2 ± 2 breaths per minute during shisha smoking.

Shisha smoking also reduces blood flow and oxygen delivery. Nitric oxide (NO) levels—while important for blood vessel relaxation—are abnormally elevated in shisha smokers. One case-control study found serum NO levels of 34.3 micromole/L (95% CI 27.8-42.3) in shisha smokers versus 22.5 micromole/L (95% CI 18.4-27.6) in non-smokers, a significant difference linked to inflammation and cardiovascular strain.

Metabolic Syndrome: A Cluster of Risks

Shisha smokers are significantly more likely to develop metabolic syndrome, a dangerous cluster of conditions that increase the risk of heart disease, stroke, and diabetes. The specific odds ratios (OR) found in the review—which represent how much more likely shisha smokers are to have these conditions compared to non-smokers—are striking:

Hypertriglyceridemia (high blood fats): OR 1.63 (95% CI, 1.25-2.10)
Hyperglycemia (high blood sugar): OR 1.82 (95% CI, 1.37-2.41)
Hypertension (high blood pressure): OR 1.95 (95% CI, 1.51-2.51)
Abdominal obesity (excess belly fat): OR 1.93 (95% CI, 1.52-2.45)

In plain language: shisha smokers are approximately 1.6 to 2 times more likely to have these serious metabolic abnormalities than non-smokers.

Effects on the Larynx (Voice Box)

A case-control study in Beirut found that 21.5% of shisha smokers had benign lesions of the vocal cords and vocal folds. Edema (swelling of the vocal cords) was the most common finding, present in 16% of cases, followed by cysts at 4.8%. These changes can cause hoarseness, voice changes, and breathing difficulties.

Oral Health Effects

Shisha smoking wreaks havoc on the mouth. Documented effects include:

Staining of teeth and dental restorations (fillings)
Reduced ability to smell and taste
Periodontal (gum) bone loss
Dry sockets after tooth extraction
Oral squamous cell carcinoma (a type of mouth cancer)

Effects on Pregnancy and Newborns

Pregnant women who smoke shisha put both themselves and their babies at serious risk. The review found that smoking one or more shisha per day during pregnancy is associated with at least a 100-gram (3.5-ounce) reduction in infant birth weight. Even more concerning, the risk of delivering a low-birth-weight baby almost triples among women who smoke shisha during their first trimester.

Another study (Tamim H) found that mothers who smoked shisha had significantly higher odds of delivering low-birth-weight infants compared to non-smoking mothers—an odds ratio of 2.4 (95% CI, 1.2-5.0), meaning they were nearly two and a half times more likely to have a low-birth-weight baby.

Shisha smoking during pregnancy is also associated with other complications, including:

Lower APGAR scores (a quick assessment of a newborn's health measured at 1 and 5 minutes after birth)
Increased pulmonary (lung) problems at birth

Cancer Risks Linked to Shisha Smoking

One of the most alarming aspects of shisha smoking is its link to multiple types of cancer. Because shisha smoke contains dozens of carcinogens—including naphthalene, acenaphthylene, acenaphthene, fluorene, phenanthrene, and anthracene—it's no surprise that cancer risk is elevated.

Carcinoembryonic antigen (CEA), a marker of malignant transformation and chronic inflammation, is increased in shisha smokers and is associated with a variety of cancers.

Esophageal Cancer

While cigarette smoking is an established risk factor for esophageal cancer (cancer of the food pipe), there has been little information about shisha's role. This review found that there is a significant association between esophageal carcinoma and shisha smoking, with an odds ratio of 1.85 (95% CI, 1.41-2.44). This association has also been confirmed in studies from China, India, and Iran.

Pancreatic Cancer

Cancer of the pancreas is a rapidly fatal disease, and it is significantly associated with tobacco smoking. The disease is caused by damage (mutations) to DNA, and smoking is a major risk factor. Cigars and shisha are both known to increase the risk of developing pancreatic cancer.

Prostate Cancer

One study (Hosseini M) reported that shisha smoking is one of the risk factors for prostate cancer, making it a concern for male smokers.

Bladder Cancer

In a study of 100 cases of bladder cancer, 5% of patients were shisha users. The burning charcoal used in shisha produces smoke containing constituents that are initiating factors for carcinoma development. However, the evidence is mixed: one cancer-hypothesis review (Prignot et al.) concluded that the data indicate "an increased risk, but not bladder cancer (Egypt)," suggesting the link may be partially confounded by other factors in some populations.

Lung Cancer

While the original text is partially cut off in the provided excerpt, the abstract clearly states that increased risks of carcinoma are linked to shisha, with carcinomas of the pancreas and lung being at the forefront.

Genetic and Cellular Damage

Shisha smoke doesn't just harm tissues—it damages DNA itself. Compared to non-exposed controls, shisha use was associated with a significant increase in the frequency of chromosomal aberrations (abnormalities in chromosome structure or number) and sister chromatid exchanges (a type of DNA damage). The frequency of satellite associations and the mitotic index (a measure of cell division) were also significantly higher in water pipe users relative to controls.

That said, some investigators have contradicted these findings, and there is a nuance worth understanding. In contrast to cigarettes, hookah generates almost no side-stream smoke (the smoke that drifts off the burning end of a cigarette) because of the charcoal topping on the bowl and the lower temperature of the tobacco. The main smoke that is inhaled has been "filtered" at the level of the bowl, inside the water, along the length of the hose, and then by the smoker's lungs themselves. Some research suggests this resulting smoke is less toxic than cigarette side-stream smoke.

Studies also show that shisha smoke is 3 times less concentrated than cigarette smoke in terms of particles—74.4 x 10⁹ particles for a 1000 ml hookah (machine-produced) puff versus 9.24 x 10⁹ for a 45 ml cigarette "puff." One study (Sajid et al.) reported that heavy smokers—those spending up to 6 hours per day in 3 to 8 smoking sessions using a tobacco weight equivalent to about 60 cigarettes—had significantly elevated CEA levels.

But here's the critical point: even if shisha smoke is less concentrated, shisha smokers consume vastly more smoke per session. The trade-off between lower concentration and much higher volume means shisha smokers end up exposed to more—not less—of many harmful chemicals.

What These Findings Mean for Patients

For anyone who smokes shisha—or knows someone who does—these findings should serve as a wake-up call. Let's be clear about what the evidence shows:

First, shisha is not a safe alternative to cigarettes. It exposes smokers to significant amounts of nicotine, tar, carbon monoxide, and heavy metals. A single session can deliver more nicotine than a cigarette, nearly 4-8 times more carbon monoxide, and a massive 802 mg of tar.

Second, the myth of water filtration is just that—a myth. The bubbles passing through water do not capture the dangerous chemicals in tobacco smoke. Smokers are still inhaling carcinogens, and the charcoal adds its own toxic compounds to the mix.

Third, the health consequences are real, measurable, and serious. Shisha smoking affects nearly every organ system: it damages the heart and blood vessels, disrupts metabolism, harms the lungs and voice box, damages teeth and gums, causes pregnancy complications, and increases the risk of multiple cancers including pancreatic, lung, esophageal, and prostate cancer. The genetic damage observed in shisha smokers is a direct pathway to cancer development.

Fourth, shisha is not just a personal choice—it affects others. The high social acceptance of shisha means increased secondhand smoke exposure for friends and family members in lounges and homes.

The misconception that shisha is "lighter" and easier to quit than cigarettes is also dangerous. While nicotine peaks are similar, the longer duration of shisha sessions means greater overall nicotine exposure, which can be just as addictive—if not more so—than cigarette smoking.

What This Review Couldn't Prove

While this review provides a comprehensive look at the harms of shisha, it's important to understand its limitations:

Qualitative overview: The review is a literature review and qualitative synthesis, not a single controlled experiment. As such, it can show associations but cannot definitively prove cause-and-effect for every health outcome.
Conflicting evidence on some outcomes: The review notes that some investigators have contradicted findings regarding genetic damage, and the bladder cancer link is debated in some analyses (such as the Prignot review).
Limited research on shisha specifically: Compared to cigarettes, very little is known about the health effects of shisha use. Many claims rely on a limited number of studies.
Geographic gaps: There are very few studies on shisha prevalence in some countries, including Pakistan, and data from other regions is uneven.
Publication date: This review was published in 2014. While the core findings about the harms of tobacco remain valid, more recent research may provide additional data.
Cultural and regional variation: Shisha devices, tobacco types, and smoking patterns vary widely between regions, which may affect how generalizable the findings are.

Recommendations for Patients and Families

Based on this review, here's practical advice for anyone affected by shisha smoking:

If you don't smoke shisha, don't start. The evidence is clear that shisha is harmful, and the misconception that it's safer than cigarettes is simply wrong. Avoid social pressure and remember that "social" smoking is still smoking.
If you currently smoke shisha, make a quit plan. The nicotine in shisha is addictive, and the health effects are cumulative. Talk to your healthcare provider about strategies for quitting, including counseling, nicotine replacement therapy, and support groups.
If you're pregnant or planning to become pregnant, quit immediately. The risk of low birth weight and newborn complications is substantial. Smoking shisha in the first trimester nearly triples the risk of delivering a low-birth-weight baby.
Don't substitute shisha for cigarettes. Shisha is not a "reduced risk" product. It delivers comparable or greater amounts of nicotine and other toxins than cigarettes.
Avoid secondhand shisha smoke. If friends or family members smoke shisha, step outside or stay at a distance. The smoke is harmful to children, pregnant women, and people with respiratory or heart conditions.
Be skeptical of flavored and "herbal" shisha. Even tobacco-free shisha produces harmful smoke, and the charcoal itself releases carbon monoxide and carcinogens.
Educate yourself and others. Share this information with young people who may be attracted to shisha's social appeal, flavors, and perceived safety. Many of the 15 reasons people choose shisha are based on myths that the evidence debunks.
If you smoke shisha and are over 40, or have any concerning symptoms—such as persistent hoarseness, difficulty swallowing, mouth sores that don't heal, cough, or unexplained weight loss—talk to your doctor about cancer screening and other relevant tests.
Check your cardiovascular and metabolic health. Shisha smokers should have their blood pressure, blood sugar, and cholesterol checked regularly, given the significantly higher odds of hypertension, hyperglycemia, and abnormal cholesterol levels.
Protect your oral health. If you smoke shisha, schedule regular dental checkups, as shisha is a notable risk factor for gum (periodontal) disease and oral cancers.

Public health campaigns must do more than warn about cigarettes—they must specifically target shisha use and dispel the myths that make it attractive, especially among young people. It's time to recognize shisha for what it is: a "virulent strain" in the tobacco epidemic, with consequences that can last a lifetime.

Frequently Asked Questions

Is shisha (hookah) smoking safer than cigarettes?

No. A single shisha session can expose a smoker to 1.7 times the nicotine of one cigarette, nearly 4 times more carbon monoxide than an entire cigarette, and 802 mg of tar. The water does not filter out harmful chemicals. Studies show many users mistakenly believe shisha is less harmful, but research indicates it carries serious health risks similar to or greater than cigarettes.

What are the health risks of smoking shisha during pregnancy?

Smoking one or more shisha per day during pregnancy is linked to at least a 100-gram reduction in infant birth weight. Women who smoke shisha in the first trimester have nearly triple the risk of delivering a low-birth-weight baby. One study found shisha-smoking mothers had 2.4 times higher odds of a low-birth-weight infant, along with lower APGAR scores and increased lung problems in newborns.

Can shisha smoking cause cancer?

Yes. The review found significant links between shisha smoking and esophageal cancer, with an odds ratio of 1.85. It also linked shisha to pancreatic, lung, and prostate cancers. Shisha smoke contains dozens of carcinogens, including naphthalene, phenanthrene, and anthracene. Bladder cancer was seen in 5% of patients in one study, though evidence for that link is mixed.

How does shisha smoke affect the heart and blood?

A single shisha session increases heart rate and blood pressure within 45 minutes. It reduces heart rate variability, lowers good (HDL) cholesterol, and raises bad (LDL) cholesterol and triglycerides. Shisha smoking also increases oxidative stress markers and carbon monoxide levels, which can starve the body of oxygen. These changes raise cardiovascular risk and can promote blood clots.

Does the water in a shisha pipe filter out harmful chemicals?

No. The evidence shows that volatile carcinogens and other particles in tobacco smoke stay within the air bubbles as they pass through the water. So water does not make shisha less harmful than cigarettes. The charcoal adds extra toxins, and a shisha smoker inhales far more smoke in one session than a cigarette smoker, leading to greater exposure to harmful chemicals.

Is shisha less addictive than cigarettes because nicotine levels are lower?

No. Although the peak nicotine concentration may be similar, a shisha session lasts much longer, so total nicotine exposure is greater. In one pharmacokinetic model, a shisha session delivered 1.7 times the nicotine dose of a single cigarette. The review warns that this greater overall nicotine exposure can make shisha just as addictive, if not more so, than cigarettes.

What should I do if I want to quit smoking shisha?

Make a quit plan and talk to your healthcare provider about counseling, nicotine replacement therapy, and support groups. Avoid social situations that pressure you to smoke. Do not substitute shisha for cigarettes or use flavored or herbal versions, since they still produce harmful smoke. Regular checkups of blood pressure, blood sugar, and cholesterol are also recommended because shisha increases risks of metabolic problems.

When should a shisha smoker with symptoms like persistent hoarseness, mouth sores, or unexplained weight loss seek a second medical opinion?

A second opinion is wise if you smoke shisha and have persistent hoarseness, difficulty swallowing, mouth sores that don't heal, a chronic cough, or unexplained weight loss—especially if you are over 40—because these can signal cancers of the lung, pancreas, esophagus, or mouth linked to shisha. Regular checks of blood pressure, blood sugar, and cholesterol are also advisable because shisha roughly doubles the odds of hypertension, high blood sugar, and abnormal belly fat. A second opinion can confirm whether further cancer screening or metabolic treatment is needed. Diagnostic Detectives Network provides independent expert second opinions.

When should a shisha smoker with persistent hoarseness, mouth sores, or unexplained weight loss seek a second opinion?

A second opinion is reasonable if you smoke shisha and have persistent hoarseness, difficulty swallowing, mouth sores that don't heal, a chronic cough, or unexplained weight loss, especially over age 40, since these can signal cancers of the lung, pancreas, esophagus, or mouth linked to shisha. Shisha roughly doubles the odds of hypertension, high blood sugar, and abnormal belly fat, so blood pressure, blood sugar, and cholesterol checks are also advisable. A second opinion can confirm whether further cancer screening or metabolic treatment is needed. Diagnostic Detectives Network provides independent expert second opinions.

Source Information

Original article title: Harmful effects of shisha

Authors: Hafiz Muhammad Aslam, Shafaq Saleem, Sidra German, and Wardah Asif Qureshi

Journal: International Archives of Medicine, 2014, Volume 7, Article 16

DOI/URL: http://www.intarchmed.com/content/7/1/16

Affiliations: Dow Medical College, Dow University of Health Sciences, Karachi, Pakistan

Access: This is an Open Access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

This patient-friendly article is based on peer-reviewed research published in International Archives of Medicine. It has been adapted to make the findings more accessible to a general audience while preserving all key data, statistics, and conclusions from the original scientific paper. This content is for educational purposes and is not a substitute for professional medical advice, diagnosis, or treatment. Always seek the advice of your physician or another qualified health provider with any questions you may have regarding a medical condition.

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