Shisha smoking: the facts behind the social ritual

Is shisha really less harmful than cigarettes?

The widespread belief that passing smoke through water removes its hazards is not supported by the science. Water cools and moistens the smoke, making it easier to breathe in deeply, but it does not filter out nicotine, carbon monoxide, heavy metals or carcinogens. All of these pass through freely. In fact, the cooled smoke causes less throat irritation, which encourages users to inhale more deeply than they would with a cigarette.

A 2011 study published in Cancer Epidemiology, Biomarkers and Prevention measured the chemicals in smokers' blood after a single shisha session. Nicotine, carbon monoxide and known carcinogens all rose significantly, in some measures to levels that exceeded what several cigarettes would produce. The participants in that study believed before testing that shisha was much safer than cigarettes. The blood results contradicted that belief clearly.

A standard shisha session lasting 45 to 60 minutes typically involves 100 to 200 puffs, each much deeper than a cigarette puff. A single cigarette produces 8 to 12 puffs. The cumulative exposure in one session regularly exceeds what dozens of cigarettes would produce in terms of raw smoke volume inhaled. The comparison is not about the strength of the tobacco but about the total time spent drawing smoke into your lungs.

The fruit and sweet flavourings added to shisha tobacco add a further layer of deception. When smoke tastes of apple or mint or vanilla, it is psychologically harder to connect it with the image of harmful tobacco. The flavouring changes nothing in the chemistry. Carcinogens, nicotine and carbon monoxide are present regardless of what the smoke tastes like.

Carbon monoxide: the silent gas in every session

Carbon monoxide (CO) is a colourless, odourless gas produced whenever any fuel burns incompletely. In shisha, the charcoal generates CO continuously throughout the session. This gas binds to haemoglobin in the blood hundreds of times more tightly than oxygen does, directly reducing the oxygen your tissues receive with every breath.

A study in Atmospheric Environment measured CO in shisha smoke versus cigarette smoke and found that the side-stream smoke from shisha released substantial CO that affected non-smokers sitting in the same room. Spectators at a shisha cafe absorb elevated CO even without touching the pipe. In enclosed spaces with poor ventilation, CO accumulates quickly and affects everyone present, not just the person smoking.

After a session, the mild headache and nausea that many shisha smokers dismiss as normal are textbook signs of mild CO poisoning. Many people attribute these symptoms to tiredness or to sitting in one place for too long, not realising that the actual cause is reduced oxygen supply to the brain.

For your heart, elevated CO means it is working against a double burden: less available oxygen and a cardiovascular system already under nicotine-driven stress. This combination accelerates the kind of wear that leads to heart disease over time. With repeated sessions, this accumulated strain is a real contributor to earlier cardiovascular ageing.

What shisha does to your lungs

A 2019 review in the Annals of the American Thoracic Society gathered the available evidence on the pulmonary effects of hookah use. It found that regular shisha smokers show declines in lung function comparable to regular cigarette smokers, with increased rates of chronic obstructive pulmonary disease (COPD), asthma exacerbations and lung infections. Morning cough that many smokers dismiss as trivial is a sign of chronic airway irritation, not a harmless clearing of the throat.

The fine particles in shisha smoke are small enough to reach the deepest parts of the lung, the alveoli, where gas exchange with the blood takes place. Once there, they do not leave with exhalation. They remain embedded in tissue. Repeated inflammation at this level leads to gradual scarring and loss of elasticity in the lung tissue over time.

Unlike an acute illness, this damage accumulates quietly over years before symptoms appear. The delay between exposure and symptoms is the reason many longtime shisha smokers do not connect their shortness of breath on exertion with sessions from years earlier. By the time lung function is noticeably reduced, the habit has often continued for a decade or more.

Studies have documented that measurable shortness of breath and reduced exercise capacity appear on average after several years of regular shisha use. At that stage, the damage cannot be fully reversed. Stopping does slow further decline significantly, which is why quitting at any point is worth doing.

Heart and blood vessel risks

A 2019 review in Nicotine and Tobacco Research documented that shisha smoking raises blood pressure, increases heart rate and accelerates arterial stiffening. These changes are measurable after a single session and compound with regular use. Ultrasound studies have documented arterial stiffening in young shisha smokers who had no pre-existing heart problems, showing that the damage begins well before any symptoms.

Nicotine activates the sympathetic nervous system, constricting blood vessels and raising blood pressure. Combined with CO reducing oxygen delivery, the heart is doing more work with less oxygen. This is precisely the condition that triggers angina in people with narrowed arteries and, in vulnerable individuals, heart attacks.

For someone with pre-existing high blood pressure, diabetes or coronary artery disease, each shisha session adds a meaningful acute cardiovascular risk. The risk does not disappear simply because the sessions are infrequent. The acute physiological effect begins within minutes of starting each session.

Shisha smoking is not always recorded as a cardiovascular risk factor because clinicians sometimes do not ask about it specifically. If you smoke shisha, mention it explicitly to your doctor when discussing blood pressure or heart risk. It belongs in your medical history in the same way that cigarettes do.

Infection risk from sharing the pipe

Sharing a shisha mouthpiece is functionally similar to sharing saliva directly. Herpes simplex virus type 1 (oral herpes), tuberculosis, hepatitis A and influenza have all been documented as transmitting through shared waterpipe use. A personal plastic mouthpiece reduces but does not eliminate the risk, because the hose, the pipe body and the smoke itself are still shared.

In cafe settings, the hose and pipe body are rarely sterilised between customers. The 2021 Syrian study in PLOS ONE that tracked smoking patterns during years of displacement found widespread shisha use in social settings with shared equipment, a combination that creates sustained transmission opportunities for respiratory and oral infections.

Oral ulcers and throat inflammation are also more common in regular shisha smokers, and these disruptions to the mucosal barrier make infection easier to establish when sharing equipment.

Shisha and cancer: what the evidence shows

A 2022 review in the Journal of Oral Biology and Craniofacial Research examined the cancer evidence and found that shisha smokers are exposed to established carcinogens including benzopyrene, nitrosamines and fine particles that are linked to cancers of the lung, mouth, oesophagus and bladder. The evidence for lung cancer is the strongest, but oral cancer is particularly relevant because the smoke contacts the oral mucosa directly at high concentrations.

The 2010 study in Atmospheric Environment quantified carcinogen output from waterpipe versus cigarette side-stream smoke and found substantial emissions that exposed bystanders, not just the smoker. This matters in a household or cafe setting where others are present throughout a session.

A difficulty in studying shisha-specific cancers is that many regular shisha smokers also smoke cigarettes, making it hard to isolate the contribution of each. The underlying mechanism, however, is clear: large quantities of documented carcinogens delivered to sensitive tissue increase cancer risk, regardless of how the tobacco is smoked.

Does shisha cause addiction?

Yes. The nicotine in shisha is pharmacologically identical to the nicotine in cigarettes. The brain builds dependence on nicotine regardless of the route of delivery. When nicotine binds to receptors in the brain it triggers a dopamine release that produces a brief sense of calm and pleasure, and this is precisely what drives the body to repeat the experience.

Fruit-flavoured tobacco makes shisha more palatable and lowers the barrier to starting, which is why it draws in younger users who might not have begun with cigarettes. Someone who finds cigarette smoke too harsh may find shisha an easy first step into nicotine dependence. After several months, a real biological dependence has formed that has nothing to do with the pleasantness of the flavour.

Withdrawal symptoms when stopping shisha are the same as those from quitting cigarettes: irritability, difficulty concentrating, anxiety and intense cravings. Many people who smoke socially a few times a month find after a year that they cannot comfortably pass a social evening without it. The craving is not a preference, it is a neurological demand.

The 2014 Health Policy and Planning paper on tobacco in the Arab world described shisha as the primary gateway into tobacco use for younger generations in the region, particularly for those who do not consider themselves smokers. Research across Qatar, Lebanon, Syria and Jordan has documented this pattern consistently, with shisha use rising among young people who reject cigarettes on cultural or aesthetic grounds.

When to get help quitting

If you smoke shisha more than once a week and find it difficult to stop, that is dependence and it deserves support in the same way cigarette addiction does. Nicotine replacement therapies such as patches and gum work for shisha dependence because the underlying biology is the same. Prescription medications used for smoking cessation are also relevant.

If you have a persistent cough, feel short of breath more quickly than you used to, or notice that physical exertion leaves you more breathless than your peers, these are worth investigating. A spirometry test measuring how much air your lungs can move in one second is a simple, painless starting point.

Cutting down is better than nothing. Reducing session frequency lowers total exposure to harmful substances. But the goal supported by the evidence is complete cessation. Every session stopped is a session of accumulated damage avoided.

Sources

• Jacob P 3rd, Abu Raddaha AH, Dempsey D et al: Nicotine, carbon monoxide, and carcinogen exposure after a single use of a water pipe, Cancer epidemiology, biomarkers & prevention : a publication of the American Association for Cancer Research, cosponsored by the American Society of Preventive Oncology, 2011
• Patel MP, Khangoora VS, Marik PE et al: A Review of the Pulmonary and Health Impacts of Hookah Use, Annals of the American Thoracic Society, 2019
• Rezk-Hanna M, Benowitz NL: Cardiovascular Effects of Hookah Smoking: Potential Implications for Cardiovascular Risk, Nicotine & tobacco research : official journal of the Society for Research on Nicotine and Tobacco, 2019
• Kakaje A, Alhalabi MM, Alyousbashi A et al: Smoking habits and the influence of war on cigarette and shisha smoking in Syria, PloS one, 2021
• Maziak W, Nakkash R, Bahelah R et al: Tobacco in the Arab world: old and new epidemics amidst policy paralysis, Health policy and planning, 2014
• Daher N, Saleh R, Jaroudi E et al: Comparison of carcinogen, carbon monoxide, and ultrafine particle emissions from narghile waterpipe and cigarette smoking, Atmospheric environment (Oxford, England : 1994), 2010
• Patil S, Mahuli AV, Warnakulasuriya S et al: Effects of smoking shisha, cancer risk, and strategies for prevention of shisha habit, Journal of oral biology and craniofacial research, 2022