Lung Cancer
Read Time: 2 mins

Waterpipe Tobacco Smoking and the Lungs — Short Notice

Copy Link
Published Online: Sep 18th 2018 US Respiratory & Pulmonary Diseases. 2018;3(1):25–6 DOI:
Authors: Yousser Mohammad, Loai Nahass, Ismael Zakaria, Bisher Sawaf
Quick Links:
Article Information

Waterpipe tobacco smoking (WTS) is increasingly popular among young people. Although perceived to be safer than cigarettes as
smoke is filtered through water, narghile smoke is rich in carbon monoxide, as well as containing numerous toxins and carcinogens.
Detrimental effects of WTS may include nicotine addiction, bronchitis, chronic obstructive pulmonary diseases and enhancing asthma
susceptibility and exacerbations.


Waterpipe smoking, narghile, asthma, bronchitis, chronic obstructive pulmonary disease



Waterpipe tobacco smoking (WTS) has been considered a global threat and has been designated as an epidemic by public health officials. WTS is also known as “narghileh” or “narghile”, “shisha” or “hookah”. WTS involves the passage of charcoal-heated air through a perforated aluminum foil and across the tobacco mixture to become smoke that bubbles through water before being inhaled by the smoker (Figure 1).1 WTS has surged in popularity among young people in the United States and across the globe.2

The increased use of WTS is associated with migration, especially from the Eastern Mediterranean and India; tourism; and the social gatherings of narghileh smokers.1 In addition, there is a mistaken belief that it is less harmful compared with cigarette smoking.1 The idea of the narguileh being less injurious than cigarettes is due to the notion that shisha-inhaled smoke is filtered when passing through the water. However, narguileh smoke is rich in carbon monoxide, which could cause syncope if a large enough quantity of narghile is smoked, due to the formation of carboxyhemoglobin.1,3 Both active and passive narghileh smoke also contains the same intoxicants as cigarettes, and although it is filtered through water, filtering does not remove all toxins, and WTS can lead to nicotine addiction. In addition, many carcinogens (polycyclic aromatic hydrocarbons and nitrosamines) are also delivered to the body leading to an increase in incidence of lung, esophagus, bladder, and other cancers. WTS is also associated with ischemic heart diseases,
and hypertension.1,4

Similarly, WTS affects airway diseases. Several studies have confirmed the harmful effect of WTS on the lungs causing bronchitis and/or chronic obstructive pulmonary diseases (COPD) and enhancing asthma susceptibility and exacerbations. In a study among female active smokers of narguileh in Syria, chronic bronchitis was found in 70% of smokers. Lung function tests showed alteration of small airway functioning in all individuals as indicated by maximum mid expiratory flow, and forced expiratory volume in one second (FEV1) was altered in 37% of subjects, which resulted in the classification of moderate to severe COPD.5 Cigarettes and WTS have a synergistic effect on COPD onset and severity as shown by lung function. Passive smoking of cigarettes or narguileh is also associated with COPD, especially in women.6 In the International Study of Asthma and Allergies in Childhood (ISAAC), in utero and/or early life exposure to passive WTS is associated with asthma onset in children.7 Exposure to passive smoking of narguileh or cigarettes also exacerbates existing asthma.8

The WHO Framework Convention on Tobacco Control (WHO-FCTC) Secretariat has worked to establish a network of six knowledge hubs within academic institutions. Each of these hubs specializes in a given area, such as taxation, waterpipe and smokeless tobacco use, or research and surveillance, and assists groups with implementing their work, not least through analyzing and disseminating information.9 Greater collaboration between the WHO-FCTC and the wider community will enhance the appreciation of the detrimental effects of WTS. This is essential to prevent the increased incidence of COPD and asthma in at-risk populations.

Article Information:

Yousser Mohammad, Loai Nahass, Ismael
Zakaria and Bisher Sawaf have no conflicts of interest to
disclose in relation to this article.

Review Process

This article is a short opinion piece
and has not been submitted to external peer reviewers.
A member of the Editorial Board reviewed the article
before publication.


The named authors meet the International
Committee of Medical Journal Editors (ICMJE) criteria
for authorship of this manuscript, take responsibility
for the integrity of the work as a whole, and have
given final approval for the version to be published.


Yousser Mohammad. Department of Internal Medicine, Tishreen University, Latakia, Syria. E:


No funding was received in the publication of this article.


This article is published under the Creative
Commons Attribution Non-commercial License, which
permits any non-commercial use, distribution, adaptation,
and reproduction provided the original authors and source
are given appropriate credit. © The Authors 2018.




  1. World Health Organization. WHO Study Group on Tobacco Product Regulation. Advisory note: waterpipe tobacco smoking: health effects, research needs and recommended actions by regulators – 2nd ed. Switzerland: WHO Press, 2015.
  2. Maziak W, Taleb ZB, Bahelah R, et al. The global epidemiology of
    waterpipe smoking. Tob Control. 2015;24(Suppl 1):i3–12.
  3. World Health Organization. Control and prevention of waterpipe tobacco products (document FCTC/COP/6/11). Presented at: Conference of the Parties to the WHO Framework Convention on Tobacco Control, Moscow, Russian Federation,
    October 13–18, 2014.
  4. Chaouachi K. Use & misuse of water-filtered tobacco smoking
    pipes in the world. Consequences for public health, research & research ethics. Open Med Chem J. 2015;9:1–12.
  5. Mohammad Y, Kakah M, Mohammad Y. Chronic respiratory effect of narguileh smoking compared with cigarette smoking in women from the East Mediterranean region. Int J Chron Obstruct Pulmon Dis. 2008;3:405–14.
  6. Mohammad Y, Shaaban R, Abou Al-Zahab B, et al. Impact of active and passive smoking as risk factors for asthma and COPD in women presenting to primary care in Syria: first report by the WHO-GARD survey group. Int J Chron Obstruct Pulmon Dis. 2013;8:473–82.
  7. Lai CKW, Beasley R, Crane J, et al. Global variation in the prevalence and severity of asthma symptoms: phase three of the International Study of Asthma and Allergies in Childhood (ISAAC). Thorax. 2009;64:476–83.
  8. Ellwood P, Asher I, Billo NE, et al. The Global Asthma Network rationale and methods for Phase I global surveillance: prevalence, severity, management and risk factors. Eur Respir J. 2017;49:
    pii: 1601605.
  9. World Health Organization. WHO report on the global tobacco epidemic 2017. Monitoring tobacco use and prevention policies. Switzerland: WHO Press, 2017.

Further Resources

Share this Article
Related Content In Lung Cancer
  • Copied to clipboard!
    accredited arrow-down-editablearrow-downarrow_leftarrow-right-bluearrow-right-dark-bluearrow-right-greenarrow-right-greyarrow-right-orangearrow-right-whitearrow-right-bluearrow-up-orangeavatarcalendarchevron-down consultant-pathologist-nurseconsultant-pathologistcrosscrossdownloademailexclaimationfeedbackfiltergraph-arrowinterviewslinkmdt_iconmenumore_dots nurse-consultantpadlock patient-advocate-pathologistpatient-consultantpatientperson pharmacist-nurseplay_buttonplay-colour-tmcplay-colourAsset 1podcastprinter scenerysearch share single-doctor social_facebooksocial_googleplussocial_instagramsocial_linkedin_altsocial_linkedin_altsocial_pinterestlogo-twitter-glyph-32social_youtubeshape-star (1)tick-bluetick-orangetick-red tick-whiteticktimetranscriptup-arrowwebinar Sponsored Department Location NEW TMM Corporate Services Icons-07NEW TMM Corporate Services Icons-08NEW TMM Corporate Services Icons-09NEW TMM Corporate Services Icons-10NEW TMM Corporate Services Icons-11NEW TMM Corporate Services Icons-12Salary £ TMM-Corp-Site-Icons-01TMM-Corp-Site-Icons-02TMM-Corp-Site-Icons-03TMM-Corp-Site-Icons-04TMM-Corp-Site-Icons-05TMM-Corp-Site-Icons-06TMM-Corp-Site-Icons-07TMM-Corp-Site-Icons-08TMM-Corp-Site-Icons-09TMM-Corp-Site-Icons-10TMM-Corp-Site-Icons-11TMM-Corp-Site-Icons-12TMM-Corp-Site-Icons-13TMM-Corp-Site-Icons-14TMM-Corp-Site-Icons-15TMM-Corp-Site-Icons-16TMM-Corp-Site-Icons-17TMM-Corp-Site-Icons-18TMM-Corp-Site-Icons-19TMM-Corp-Site-Icons-20TMM-Corp-Site-Icons-21TMM-Corp-Site-Icons-22TMM-Corp-Site-Icons-23TMM-Corp-Site-Icons-24TMM-Corp-Site-Icons-25TMM-Corp-Site-Icons-26TMM-Corp-Site-Icons-27TMM-Corp-Site-Icons-28TMM-Corp-Site-Icons-29TMM-Corp-Site-Icons-30TMM-Corp-Site-Icons-31TMM-Corp-Site-Icons-32TMM-Corp-Site-Icons-33TMM-Corp-Site-Icons-34TMM-Corp-Site-Icons-35TMM-Corp-Site-Icons-36TMM-Corp-Site-Icons-37TMM-Corp-Site-Icons-38TMM-Corp-Site-Icons-39TMM-Corp-Site-Icons-40TMM-Corp-Site-Icons-41TMM-Corp-Site-Icons-42TMM-Corp-Site-Icons-43TMM-Corp-Site-Icons-44TMM-Corp-Site-Icons-45TMM-Corp-Site-Icons-46TMM-Corp-Site-Icons-47TMM-Corp-Site-Icons-48TMM-Corp-Site-Icons-49TMM-Corp-Site-Icons-50TMM-Corp-Site-Icons-51TMM-Corp-Site-Icons-52TMM-Corp-Site-Icons-53TMM-Corp-Site-Icons-54TMM-Corp-Site-Icons-55TMM-Corp-Site-Icons-56TMM-Corp-Site-Icons-57TMM-Corp-Site-Icons-58TMM-Corp-Site-Icons-59TMM-Corp-Site-Icons-60TMM-Corp-Site-Icons-61TMM-Corp-Site-Icons-62TMM-Corp-Site-Icons-63TMM-Corp-Site-Icons-64TMM-Corp-Site-Icons-65TMM-Corp-Site-Icons-66TMM-Corp-Site-Icons-67TMM-Corp-Site-Icons-68TMM-Corp-Site-Icons-69TMM-Corp-Site-Icons-70TMM-Corp-Site-Icons-71TMM-Corp-Site-Icons-72