Do We Know Enough About Water Pipe Smoking?

Is water pipe smoking more harmful than other forms of tobacco use? How much nicotine does it deliver? Do we need more evidence to start fighting it globally?

These questions have been circling in the tobacco control arena for some time.


The water pipe (also known as a shisha, goza or hubbly bubbly) is a rather understudied form of nicotine delivery. Studies have already dispelled some of its myths — compared to cigarettes, water pipes are not a “lighter” way to smoke, and the water used does not filter out any harmful compounds from the smoke (1, 2).

Assessing harm

Determining the nicotine content of water pipe smoking sessions can be a challenge for tobacco control researchers. It’s difficult to assess because the nicotine delivered by a water pipe depends on what kind and how much tobacco is used in a single preparation and how long the session lasts (3, 4).

Additionally, the amount of nicotine delivered depends on the length, frequency and depth of inhalation during a smoking session. Recently, a few studies standardized these variables in an attempt to assess the harm of water pipes versus cigarettes. The findings showed that the amount of nicotine delivered by water pipes is similar to the amount delivered by cigarettes. From this, we can conclude that both smoking methods can create dependence (2, 5).

Perhaps most striking is the fact that compared to cigarette smoking, water pipe smoking results in higher plasma levels of carboxyhemoglobin and a more than 50-fold increase in inhaled smoke volume, which in turn may correlate to more disease and death (2).

Measuring use

The challenge in assessing the harmful effects of water pipes is not confined to evaluating biochemical processes — monitoring its use is also difficult, as many water pipe smokers do not perceive themselves as smokers. Rather, they believe they simply engage in “social smoking” (6).

Compared to cigarette smoking, water pipe smoking indeed has a strong social appeal — it is done by groups of people in designated cafes for extended periods of time, and smokers can share the mouth piece of the water pipe. And since water pipe smoke has a distinct and pleasant aroma, it strengthens smokers’ false belief that it’s less harmful than cigarettes.

Ultimately, this encourages smokers to smoke more — until they eventually become daily smokers. Indeed, social aspects strengthen water pipe addiction (7).

Water pipes could be more harmful and more addictive than cigarettes, yet do not attract enough attention as being a very lethal nicotine delivery channel. As a growing network, Global Bridges is well-positioned to tackle this new emerging epidemic by sharing best practices and treatment programs that could be tailored toward water pipe use.

What best practices and treatments have you found that work for water pipe smokers?

  1. Maziak W. The global epidemic of waterpipe smoking. Addictive Behaviors. 2011;36:1.
  2. Cobb CO, et al. Waterpipe tobacco smoking and cigarette smoking: A direct comparison of toxicant exposure and subjective effects. Nicotine & Tobacco Research. 2011;13:78.
  3. Chaouachi K. Assessment of narghile (shisha, hookah) smokers’ actual exposure to toxic chemicals requires further sound studies. Libyan Journal of Medicine. 2011;11:6.
  4. Vansickel AR. Waterpipe tobacco products: Nicotine labeling versus nicotine delivery. Tobacco Control. 2011 Jun 2.
  5. Rastam S, et al. Comparative analysis of waterpipe and cigarette suppression of abstinence and craving symptoms. Addictive Behaviors. 2011;36:555.
  6. Kulwicki A, et al. Arab-American adolescent perceptions and experiences with smoking. Public Health Nursing. 2003;20:177.
  7. Nakkash RT, et al. The rise in narghile (shisha, hookah) waterpipe tobacco smoking: A qualitative study of perceptions of smokers and non-smokers. BMC Public Health. 2011;11:315.