This comprehensive review reveals that shisha (water pipe) smoking carries significant health risks comparable to or greater than cigarette smoking, including increased risks of low birth weight infants, cardiovascular problems, various cancers, and metabolic disorders. Despite common misconceptions that water filtration makes it safer, research shows shisha sessions deliver higher levels of nicotine, carbon monoxide, and carcinogens than cigarettes, with particular concerns about secondhand smoke exposure and growing popularity among youth globally.

The Hidden Dangers of Shisha Smoking: A Comprehensive Patient Guide

Table of Contents

• Introduction: The Global Shisha Epidemic
• How This Research Was Conducted
• Global Prevalence Patterns
• Who Smokes Shisha: Age and Gender Patterns
• Why People Smoke Shisha: 15 Key Reasons
• Dangerous Misconceptions About Safety
• Chemical Comparison: Shisha vs. Cigarettes
• Cardiovascular System Damage
• Pregnancy and Birth Complications
• Cancer Risks Associated with Shisha
• Other Significant Health Effects
• Conclusions and Recommendations
• Source Information

Introduction: The Global Shisha Epidemic

Tobacco use remains one of the world's most significant preventable causes of illness and death, responsible for approximately 5 million deaths annually worldwide. What's particularly concerning is that half of current smokers will die prematurely from tobacco-related diseases. While cigarette smoking has received widespread attention, a newer method of tobacco use has been rapidly spreading across the globe: shisha smoking.

Shisha smoking, also known as water pipe, hookah, or narghile smoking, involves inhaling tobacco smoke that has passed through water before reaching the user. This practice dates back at least 400 years but has recently gained alarming popularity, particularly among young people. The World Health Organization and public health officials have classified shisha smoking as a global threat with epidemic status due to its rapidly increasing use patterns.

What makes shisha particularly dangerous is the widespread misconception that it's safer than cigarette smoking. Many users believe the water filtration system removes harmful chemicals, but research demonstrates this is completely false. Tobacco smoke contains over 4,800 different chemicals, with 69 known carcinogens (cancer-causing agents) and numerous tumor promoters, regardless of the delivery method.

How This Research Was Conducted

This comprehensive review analyzed all available scientific evidence on shisha smoking's health effects and global patterns. Researchers conducted an extensive search of medical databases including PubMed and Google Scholar using multiple search terms: "shisha," "water pipe," "narghile," and "hookah."

The search strategy identified 91 articles using "Shisha" (1994-2012), 94 articles for "Narghile" (1981-2013), 146 articles for "Hookah" (1982-2013), and 186 articles for "Water pipe" (1986-2013). The research team included all relevant original studies, case reports, and reviews published in English that addressed the epidemiology and health effects of shisha smoking.

The researchers applied strict inclusion criteria to ensure comprehensive coverage while excluding articles not directly relevant to understanding shisha's health impacts and usage patterns. This methodology ensured a thorough analysis of the current scientific understanding of shisha smoking's dangers.

Global Prevalence Patterns

Shisha smoking has shown alarming increases in popularity across diverse geographical regions. In the United States, prevalence rates reached 40% between 2005-2008, with specific studies showing concerning patterns:

• United States: 27.8% lifetime hookah users in two universities, 24.5% prevalence at University of San Diego, and 40.3% of people having ever tried shisha across eight universities
• Lebanon: 59.8% of 13-15 year olds had smoked shisha at least once in the past month compared to only 10% cigarette smokers
• Saudi Arabia: 12.6% prevalence among college students
• Malaysia: 19-20% prevalence in studies of university students
• Syria: 62.6% of male and 29.8% of female university students were regular shisha smokers

Pakistan showed particularly high usage rates, with studies revealing 53.6% prevalence at Aga Khan University, 49% at Institute of Business and Administration, and 61% across four major cities. These numbers demonstrate that shisha smoking has become a significant global public health concern affecting millions of users worldwide.

Who Smokes Shisha: Age and Gender Patterns

Research reveals distinct demographic patterns in shisha usage. The majority of users are young males aged 15-25 years, though concerning trends show increasing use among even younger populations and growing female participation in some regions.

Studies from the United States show shisha smokers are predominantly males aged 15-25 years. In Saudi Arabia, 63.8% of students begin shisha smoking between ages 16-18 with male dominance. Syrian users typically start at 19.2 years for males and 21.7 years for females on average.

Pakistan follows similar patterns with males representing 53.6% of users and an average age of 21 years. Most Middle Eastern countries show male predominance in shisha usage, though Jordan presents a concerning exception where more females smoke shisha than males. This trend reversal in Jordan suggests cultural factors may influence usage patterns differently across regions.

The concentration of shisha use among young people is particularly alarming given the long-term health consequences and addiction potential. Many users begin during critical developmental periods, establishing patterns that may continue for decades.

Why People Smoke Shisha: 15 Key Reasons

Research has identified multiple factors driving shisha's popularity. Understanding these reasons helps explain why this dangerous practice continues to spread despite known health risks:

1. Global Tourism and Migration: Travelers bringing hookahs from countries like Egypt and Tunisia, and hookah lounges appearing in Western countries
2. Easier Lighting Systems: New easy-to-light charcoal making shisha more convenient
3. Social Acceptance: Non-smokers tolerate shisha more due to reduced smoke irritants
4. Anti-Tobacco Campaign Backlash: Perceived as safer than cigarettes due to misinformation
5. False Sense of Filtration: Belief that water removes carcinogens (scientifically disproven)
6. Perceived "Light" Dependence: Mistaken belief that shisha is easier to quit than cigarettes
7. Media Influence: Egyptian movies and television featuring hookah smokers for decades
8. Modern Individualism: Meeting socializing needs through new forms of sociability
9. Conviviality: Social smoking, sharing the hose, conversation during long sessions
10. Powerful Symbolism: Associations with dreams, art, mysticism, and "peace pipe" imagery
11. Cross-Cultural Appeal: Social, sexual, religious, and inter-generational practice
12. Flavored Tobacco: "Muassel" - honey/molasses-based flavored mixtures
13. Cultural Status of Honey: Positive associations from religious texts (Koran, The Bees)
14. Sensory Experience: Stimulation of all five senses during smoking sessions
15. "Rebellion" Values: Expression of non-conformity and independence

Dangerous Misconceptions About Safety

False beliefs about shisha safety represent one of the most significant public health challenges. Research consistently shows that 30% of university students believe shisha is less dangerous than cigarettes, with specific studies revealing:

• 60% of Pakistani population considers cigarettes more dangerous than shisha
• 21% of Egyptian male shisha smokers prefer it due to safety misconceptions
• 49.7% of Egyptian students believe shisha is more socially acceptable than cigarettes
• 58.3% of Jordanian hookah users hold mistaken safety beliefs
• 89.06% of Jordanian university students have incorrect perceptions about shisha safety

Research proves these beliefs wrong through three critical findings. First, burning charcoal adds additional harmful toxins to the smoke. Second, a shisha smoker inhales up to 200 times more smoke in a single session compared to cigarette smokers. Third, shisha smoking creates high rates of secondhand smoke exposure due to its social acceptance and longer session durations.

The water filtration myth is particularly dangerous. Scientific evidence confirms that making air bubbles pass through water doesn't significantly change their chemical content. Volatile carcinogens and other harmful particles remain within air bubbles during water passage, making shisha at least as harmful as cigarette smoking.

Chemical Comparison: Shisha vs. Cigarettes

Scientific analysis reveals shocking differences in chemical exposure between shisha and cigarettes. During a standard smoking session using 10g of mo'assel tobacco paste with 1.5 quick-lighting charcoal disks, researchers found:

• Nicotine: 2.94 mg per session (compared to approximately 1mg per cigarette)
• Tar: 802 mg per session (extremely high compared to cigarettes)
• Carbon Monoxide: 145 mg per session (significantly higher than cigarettes)
• Carcinogens: Higher quantities of chrysene, phenanthrene, and flouranthrene

The smoking mechanics differ dramatically. Shisha sessions involve approximately 171 puffs of 0.53 liter volume each, with 2.6-second duration and 17-second intervals between puffs. This compares to about 10-12 puffs per cigarette, meaning shisha delivers 10 times more puffs at much larger volumes.

Burning temperatures also differ significantly - shisha charcoal burns at about 900°C compared to 450°C for cigarettes. This higher temperature generates more harmful compounds. Pharmacokinetic analysis shows shisha delivers 1.7 times the nicotine dose compared to cigarettes, with nicotine exposure measured at 418 ng/ml-min for shisha versus 243 ng/ml-min for cigarettes.

Cardiovascular System Damage

Shisha smoking causes significant harm to the heart and circulatory system. Within just 45 minutes of shisha use, heart rates increase significantly, with studies showing elevated systolic and diastolic blood pressure and heart rate.

Research demonstrates that shisha smoking reduces heart rate variability, indicating dysfunction in autonomic regulation of cardiac cycles. This reduced variability associates with inhalation-induced oxidative stress and increased heart rate and blood pressure. These changes represent early warning signs of cardiovascular damage.

Cholesterol profiles show concerning alterations. Shisha smokers have significantly lower HDL (good cholesterol) and ApoA levels compared to non-smokers. Meanwhile, LDL-cholesterol (bad cholesterol), ApoB, and triglycerides are significantly higher in shisha users. These lipid changes increase cardiovascular disease risk.

Antioxidant capacity suffers dramatically. Studies from Saudi Arabia show total antioxidant capacity and vitamin C levels are lower in shisha smokers than non-smokers. This reduced antioxidant protection leaves the cardiovascular system more vulnerable to damage.

Platelet function becomes impaired. Single shisha sessions increase oxidation injury (8-epi-PGF2 alpha p=0.003), MDA (p=0.001), and 11 DH=TXB2 (p=0.0003) significantly. Daily smoking induces persistent, long-lasting oxidation injury that promotes blood clot formation and cardiovascular events.

Pregnancy and Birth Complications

Shisha smoking during pregnancy creates serious risks for both mother and baby. Research shows that smoking one or more shishas daily during pregnancy associates with at least 100 grams reduction in infant birth weight. The risk of delivering low birth weight babies almost triples among women who smoke shisha during their first trimester.

Specific research findings include mothers who smoke shisha having 2.4 times higher odds (95% CI, 1.2-5) of delivering low birth weight infants compared to non-smoking mothers. Additional problems include lower APGAR scores (newborn health assessment) and increased pulmonary problems at birth.

These effects occur because nicotine and other harmful chemicals cross the placental barrier, restricting fetal growth and development. Carbon monoxide from shisha smoking binds to hemoglobin more strongly than oxygen, reducing oxygen delivery to the developing fetus.

Cancer Risks Associated with Shisha

Shisha smoking significantly increases cancer risk through multiple mechanisms. The burning charcoal adds constituents to the smoke beyond those from tobacco alone, creating additional carcinogenic compounds.

Esophageal Cancer: Significant association exists between shisha smoking and esophageal carcinoma (OR=1.85, 95% CI, 1.41-2.44). Studies from China, India, and Iran confirm this relationship.

Pancreatic Cancer: This rapidly fatal disease significantly associates with tobacco smoking. Both cigars and shisha are known to increase pancreatic cancer risk through DNA damage and mutations caused by carcinogens in the smoke.

Prostate Cancer: Research identifies shisha smoking as a risk factor for prostate cancer, though mechanisms are still being studied.

Bladder Cancer: Studies of 100 bladder cancer cases found 5% of patients were shisha users. The charcoal combustion produces additional carcinogens that affect urinary system tissues.

General Carcinogenic Effects: Shisha smoke contains naphthalene, acenaphthylene, acenaphthene, flourne, phenanthrene, and other proven carcinogens. Concentration of carcinoembryonic antigen (CEA), a marker of malignant transformation and chronic inflammation, increases significantly in shisha smoke.

Other Significant Health Effects

Beyond cancer and cardiovascular damage, shisha smoking causes multiple other serious health problems:

Carbon Monoxide Poisoning: Shisha smokers show breath CO levels of 40-70 ppm (parts per million), indicating 8-12% of blood isn't functioning properly. This compares to 30-40 ppm (5-7% blood impairment) in heavy tobacco smokers. One hookah session causes eight-fold higher CO elevation than cigarette smoking.

Respiratory Effects: Respiratory rate increases by 2±2 breaths per minute during shisha use. Serum nitric oxide concentration increases to 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, indicating inflammation.

Laryngeal Damage: Benign vocal cord lesions occur in 21.5% of shisha smokers, with edema (16%) and cysts (4.8%) being most common.

Metabolic Syndrome: Shisha smokers have significantly higher risks of:

• Hypertriglyceridemia: OR 1.63 (95% CI, 1.25-2.10)
• Hyperglycemia: OR 1.82 (95% CI, 1.37-2.41)
• Hypertension: OR 1.95 (95% CI, 1.51-2.51)
• Abdominal obesity: OR 1.93 (95% CI, 1.52-2.45)

Oral Health Damage: Shisha causes tooth staining, damage to dental restorations, reduced smell and taste ability, periodontal bone loss, dry sockets, and oral squamous cell carcinoma.

Genetic Damage: Studies show shisha use associates with significant increases in chromosomal aberrations and sister chromatid exchanges. The frequency of satellite associations and mitotic index was significantly higher in water pipe users compared to controls.

Conclusions and Recommendations

This comprehensive review establishes that shisha smoking carries significant health risks that equal or exceed those of cigarette smoking. Despite common misconceptions about water filtration providing protection, scientific evidence demonstrates that shisha delivers higher levels of nicotine, carbon monoxide, tar, and carcinogens than cigarettes.

The global prevalence of shisha smoking is increasing alarmingly, particularly among young people aged 15-25 years. This trend represents a serious public health concern given the long-term health consequences including cardiovascular disease, multiple cancer types, pregnancy complications, and metabolic disorders.

Patients should understand that no safe level of shisha smoking exists. The water filtration system does not significantly reduce harmful chemical exposure, and the social nature of shisha use creates substantial secondhand smoke risks for non-users. The prolonged session duration (often 45-60 minutes) and deeper inhalation patterns result in greater overall exposure to toxic compounds compared to cigarette smoking.

Healthcare providers should specifically ask patients about shisha use during routine screenings, as many users don't consider themselves "smokers" due to misconceptions about safety. Education efforts should target young people specifically, addressing the social factors that drive shisha use while providing accurate information about health risks.

Public health policies need to address shisha smoking with the same rigor applied to cigarette smoking, including restrictions on public use, warning labels, and age verification for purchase. The cultural acceptance and social nature of shisha use require tailored approaches that respect traditions while protecting health.

Source Information

Original Article Title: Harmful effects of shisha: literature review

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

Publication: International Archives of Medicine 2014, 7:16

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

This patient-friendly article is based on peer-reviewed research and maintains all significant findings, data points, and conclusions from the original scientific publication.