water pipe tobacco


Waterpipe, hookah, or shisha all disguise their harmful tobacco smoke in myths of water filters and sweet candy flavors. Waterpipe smoke is, in fact, deadly. Incorporating bans on waterpipes into smoke-free policies will help dispel these myths.

Ma’assel in Syria

Most water pipe smokers in Syria started smoking in the early 1990s, after the introduction of ma’assel.

In a 2002 survey of water pipe cafés in Aleppo, most water pipe smokers reported initiating smoking after 1990, a date marked by the introduction of ma’assel smoking tobacco.


The water pipe is a tobacco smoking device with roots in India, Africa, and the Middle East. Water pipes have been used for centuries, but the introduction of ma’assel in the early 1990s, a molasses-soaked smoking tobacco, triggered a surge in use outside the traditional water pipe user base of older males. Water pipes employ an indirect heat source (such as lit charcoal) to slowly burn tobacco leaves while users draw smoke down through a water chamber and into their mouths through hoses. Along with the sugary molasses, ma’assel is flavored heavily with apple, banana, orange, vanilla, and other fruit or candy tastes.

Water pipe smokers often falsely believe that this form of tobacco use is less harmful than smoking cigarettes, a notion which must be dispelled by thorough, aggressive educational efforts. When hot smoke passes through water at the base of the water pipe, the smoke cools, and is then easily and deeply inhaled by even first-time tobacco smokers. The heavily flavored and cooled water pipe smoke is inhaled in massive quantities. The water’s cooling effect may actually increase harm by enabling water pipe smokers to inhale smoke deeper into their lungs.

Ma’assel is the molasses-soaked smoking tobacco commonly burned in water pipes in the Middle East, Europe, and North America, was introduced to the world in the early 1990s.

Up to 77% of ma’assel packages indicate the percentage of ‘tar’ in the product as 0.0%. The tobacco industry deliberately misrepresents the harm posed by smoking water pipe tobacco.

Waterpipe Use

Percentage of adults currently using water pipes in Middle Eastern countries

Water pipe use has been traditionally based in the Middle East and has high prevalence in many countries in the region.


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Khattab, Adel et al. “Smoking Habits in the Middle East and North Africa: Results of the BREATHE Study.” Respiratory Medicine 106 Suppl 2 (December 2012): S16–24. doi:10.1016/S0954-6111(12)70011-2.

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Names for Water Pipes

English and Native Script and the countries where a name predominates

  • Hookah – India, Pakistan, USA, United Kingdom
  • Shisha – Armenia, Azerbaijan, Cyprus, Greece, Iraq, Italy, Lebanon, Jordan, Palestine, Syria, Turkey, Uzbekistan
  • (N)arghile – Bulgaria, Bosnia and Herzegovina, Croatia, Israel, Macedonia, Serbia
  • Qalyān – Iran
  • Dieu cay – Viet Nam
  • Hubbly-bubbly – Egypt, South Africa

Water pipe smoking has been associated with elevated risks of lung, lip, mouth, and esophageal cancers. As widespread water pipe use is a recent phenomenon, large-scale high-quality studies on the long-term health effects of water pipe are still forthcoming. However, health scientists confidently predict that water pipe smoking will cause large-scale sickness and death similar to other forms of inhaled combustible tobacco products such as cigarettes.

Water pipe use has spread beyond the Middle East and is becoming integrated into the global tobacco market. In 2012, Japan Tobacco International purchased Al Nakhla, then the world’s largest water pipe tobacco manufacturer. Other transnational tobacco companies have explored moving into the water pipe tobacco market. Otherwise-strong smoking bans in Europe and North America sometimes have specific exemptions allowing the smoking of water pipes in cafés, enabling public smoking in otherwise smoke-free areas. Water pipe use is also on the rise among adolescents and young adults on college campuses and beyond, even among people who explicitly refuse to smoke cigarettes. Researchers must quantify the harms to health of this method of tobacco use and determine the best methods to stem the rise of water pipe use around the globe.

Women and Water Pipe

Proportion of All Tobacco Users that used Water Pipe by Sex, 2011

Water pipe use is especially difficult to confront because it often happens in homes, away from where traditional social pressures and policy interventions like smoking bans can have an impact. Notably, women in Middle Eastern countries are often frowned upon for using cigarettes, as they are a form of tobacco typically consumed in public, and are more likely to pick up equally harmful water pipe use.

Waterpipe Waterpipe, hookah, or shisha all disguise their harmful tobacco smoke in myths of water filters and sweet candy flavors. Waterpipe smoke is, in fact, deadly. Incorporating bans on