Hookah smoking: a still underestimated public health issue

Hookah, a form of traditional tobacco use, is emerging as a public health issue, with a marked increase among adolescents and young adults, while the health effects associated with its consumption are becoming increasingly well-documented. An international study published in Tobacco Control warns of insufficient and still fragile data, as well as largely incomplete regulatory frameworks.[1]. The authors call for the creation of an international consortium to study shisha and its effects on health, and for the application of anti-tobacco measures from the WHO Framework Convention on Tobacco Control (FCTC) already proven to reduce the consumption of other tobacco products.

Consumption is rising in a growing number of countries, particularly among young people.

Hookah smoking (also known as shisha or water pipe smoking) is no longer a phenomenon limited to the Middle East or certain North African countries, where it has historically been very prevalent. For several decades, it has spread to other parts of the world, notably the United States, Europe, and South America, and it now reaches an increasingly younger audience. The authors note that this increase is particularly noticeable among teenagers and young adults. The consumption of this highly toxic tobacco product constitutes a public health issue.

A significant portion of this expansion stems in part from the fact that anti-smoking policies remain primarily focused on cigarettes, roll-your-own tobacco, cigarillos, and, more recently, heated tobacco. Yet, available data indicate widespread use, with over 100 million regular users worldwide, according to the estimates cited. The international surveys mentioned also show that approximately 7% of adolescents aged 12 to 16 reported using shisha tobacco in the month preceding the survey in 73 countries studied.

Risks that are still underestimated and insufficiently documented

The study highlights the misconceptions surrounding hookah smoking. Many users believe it is less harmful, less addictive, or easier to quit than other tobacco products like cigarettes or rolling tobacco. However, the authors point out that water does not effectively filter out the most dangerous substances and that cooling the smoke can even encourage deeper inhalation. In other words, the perception of less danger is based on a false premise.

However, shisha smoke is not harmless and exposes users to toxic substances comparable to, or even sometimes higher than, those found in cigarettes. The combustion of tobacco using charcoal creates a specific exposure profile, with compounds that differ both in nature and quantity from those found in cigarette smoke.

Hookah smoking is often consumed during long sessions, sometimes in specialized cafes or at home, which increases cumulative exposure to harmful substances. The authors cite biological studies showing that certain carcinogen biomarkers are sometimes higher in hookah users than in cigarette smokers, even though urinary nicotine levels may be similar or slightly lower. They also point out that hookah smoking can influence biological mechanisms related to inflammation, oxidative stress, vascular damage, and chronic diseases.

The study reviews the main health effects already associated with shisha smoking in the scientific literature. The authors cite observed links with several types of cancer, including head and neck, esophageal, lung, stomach, and bladder cancers. They also mention associations with cardiovascular disease, respiratory disease, low birth weight, periodontal disease, and certain infections such as hepatitis B and C.

The study also mentions experimental measurements revealing high levels of carbon monoxide and toxic compounds in the air of shisha cafes. This means that the risk concerns not only the consumers themselves, but also the immediate environment, although the authors note that data on passive exposure remains insufficient.

In general, the authors emphasize that the quality of evidence often remains limited. Available studies are frequently small, poorly harmonized, and insufficiently adjusted for confounding factors, particularly mixed smoking or concomitant use of other substances. Comparisons between countries are difficult.

Hookah smoking is now recognized as a significant health risk, but the exact extent of its long-term effects remains underestimated.

A social and regulatory problem

The study emphasizes that the rise of shisha smoking cannot be explained solely by individual behavior. Several structural factors are highlighted: industry marketing, incomplete or insufficiently enforced existing regulations, the social normalization of the product, its comparatively much lower price, and the proliferation of shisha cafes. These elements contribute to making shisha a product perceived as convivial, accessible, and less risky than cigarettes, particularly among young people.

Among the regulatory weaknesses, the authors point to the failure to enforce the ban on sales to minors, ineffective health warnings, low levels of taxation, and the disregard for smoking bans in many places where shisha is consumed. They believe that the provisions of the WHO treaty, the Framework Convention on Tobacco Control (FCTC), which entered into force in 2005, have only been partially transposed. According to them, this situation severely limits the effectiveness of existing tobacco control policies.

An international roadmap for shisha research

In light of this situation, the study proposes the creation of an international consortium dedicated to the study of shisha and its effects on health. This initiative, named GLOW (Global Research on WPS and Health), would aim to coordinate research, harmonize methods, and produce more robust data on a global scale. The consortium would bring together specialists from several disciplines: epidemiology, clinical science, molecular biology, toxicology, social sciences, engineering, and public health. Cultural, social, and digital dimensions should be taken into account, as well as the influence of social networks and group norms on initiation to the product.

The project also includes a component dedicated to public policies. The authors propose to more systematically evaluate the implementation of the measures provided for by the FCTC, in particular taxation, the ban on advertising, health warnings, smoke-free areas that include these products, awareness campaigns and cessation support.

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[1]Toorang F., Etemadi A., Dar NA, et al, Waterpipe smoking and health outcomes: review of evidence and road map for an international consortium, Tobacco Control, published on February 25, 2026, updated on June 22, 2026, accessed on June 23, 2026

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