The Prevalence of Waterpipe Tobacco Smoking Among the General and Specific Populations

A Systematic Review

Elie A Akl; Sameer K Gunukula; Sohaib Aleem; Rawad Obeid; Philippe Abou Jaoude; Roland Honeine; Jihad Irani


BMC Public Health. 2011;11 

In This Article


Tobacco smoking using waterpipe - also known as narguileh, hookah and shisha - is traditional to region of the Middle East (Figure 1).[1] The waterpipe device heats the tobacco using charcoal, filters the resulting smoke in a bowl of water, and directs it to a rubber pipe for inhalation.[2] The type of tobacco smoked, and the shape, the size, and the appearance of the waterpipe device vary across regions.[3]

Figure 1.

Annotated figure of a waterpipe smoking device.

A recent systematic review found that waterpipe tobacco smoking was significantly associated with lung cancer, respiratory illness, low birth weight and periodontal disease.[4] An association with bladder cancer, nasopharyngeal cancer, esophageal cancer, oral dysplasia or infertility was not ruled out.[4] Another systematic review found that waterpipe tobacco smoking negatively affects lung function and may be as harmful as cigarette smoking.[5] In spite of these deleterious health effects, waterpipe smoking is widely believed to be a less harmful form of tobacco smoking,[6] and a safer alternative to cigarette smoking.[7–9]

Recent studies have reported relatively high prevalence rates of waterpipe tobacco smoking in Middle Eastern countries,[10] but also in western countries such as the United States,[2,11] the United Kingdom,[12] and Australia.[13] In 2005, the World Health Organization (WHO) issued an advisory note calling for a better understanding of national and global trends of waterpipe tobacco smoking.[14] In 2007, the American Lung Association labeled waterpipe smoking as an 'emerging deadly trend'.[2] The association called for more research on the patterns of use of waterpipe amongst various populations and to investigate its use as part of the national surveys on youth and adult tobacco use.

The primary objective of our study was to systematically review the medical literature for the prevalence of waterpipe tobacco use among the general population as well as specific populations. A secondary objective was to identify the factors associated with waterpipe tobacco use.


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