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Smoking out the evidence on water pipe use

Published online 6 April 2015

Call for intervention on ‘dangerous’ water pipe habits which are highest in the Middle East.

Sophie Cousins

© Bill Robinson / Alamy
Health experts are calling for tougher regulations surrounding water pipe smoking, saying its popularity is undermining efforts to combat tobacco use.

The Middle East has the world’s highest prevalence of water pipe smoking, with the greatest concentration in Lebanon, Jordan and Palestine, according to Gemma Vestal from the WHO’s Tobacco Free Initiative, which took part in a meeting at the World Conference on Tobacco or Health (WCTOH) in Abu Dhabi last month.

Researchers concede there has been insufficient research on the full effects of smoking water pipes – also known as shisha, hookah or nargile – but new and unpublished studies are suggesting serious health hazards. 

“We know very little about this and virtually nothing about its long-term effects,” says Michael Weitzman from New York University (NYU) School of Medicine, who contends that water pipe smoking could claim millions of lives unless people act quickly. 

Weitzman and a colleague, Terry Gordon, are looking at the effect of water pipe smoking on indoor air quality in homes. Their study, which has not yet been published, collected air samples from 33 homes in Dubai before, during and after water pipe smoking took place inside.

They found that airborne concentrations of particulate matter, black carbon and carbon monoxide were as high as levels they had previously measured in hookah bars in New York City. While a closed door could reduce the spread of pollutants; it did not completely prevent their dispersal to other areas of the home. 

“Second-hand smoke produced by household hookah smoking poses a significant danger to children and adults alike,” says Weitzman.  

Weitzman and other health experts note that while cigarette use has declined more than 30% in the past decade, water pipe smoking is growing more popular. If it remains unregulated, it will thwart tobacco control efforts.

Tougher regulation

Regularly using a water pipe will very likely take a person down the same vicious road of dependence and disease suffered by cigarette smokers.

Mohammed Jawad from the School of Public Health at Imperial College London says that water pipe smoking could be as harmful as cigarettes. He says health experts have to agree on “a unified message of harm” and calls for doctors to routinely ask patients about their water pipe smoking use. 

“We need to get some evidence-based interventions out there,” he adds. “Water pipe [now] is how cigarettes were 70 years ago – just the norm. It’s history repeating itself.” 

Alan Shihadeh from the American University of Beirut (AUB) has similar concerns. “We have learned that water pipe smoke contains abundant quantities of the same chemicals that cause addiction, cancer, lung disease and cardiovascular disease in cigarette smokers,” he says. 

“All the available scientific evidence points in the same direction: that regularly using a water pipe will very likely take a person down the same vicious road of dependence and disease suffered by cigarette smokers.”

Experts at the Abu Dhabi conference agreed that banning water pipe smoking at this stage would be extremely difficult given its increasing demand, but called for more regulation similar to tobacco smoking.

Researchers from AUB, the Arab region and the US have compiled relevant research over the last two decades, published in a supplement in Tobacco Control1, and recommend that existing laws be strengthened and revised to appropriately address water pipe tobacco use.

Rima Nakkash, associate professor at the Faculty of Health Sciences at AUB, says a major issue is that current legislation does not stipulate that health warnings should be placed on water pipe apparatus and accessories. 

The research done so far has been limited in scope, but the authors collated all peer-reviewed publications on the issue since 1991 and concluded that sufficient evidence existed to support public health interventions which present water pipe tobacco as a “serious inhalation hazard.”  

“This is a global epidemic, it’s not just endemic in the Middle East,” says Weitzman


  1. Jawad, M. et al. Waterpipe tobacco smoking legislation and policy enactment: a global analysis. Tobacco Control http://dx.doi.org/10.1136/tobaccocontrol-2014-051911 (2015)