What are the health risks of shisha smoking versus e-cigarette use for a patient trying to quit smoking or reduce nicotine intake?

Health Risks: Shisha vs E-Cigarettes

Both shisha (hookah/waterpipe) and e-cigarettes pose significant health risks and should be avoided entirely—neither is a safe alternative to smoking, and proven smoking cessation methods (behavioral counseling plus FDA-approved pharmacotherapy) should be used instead. 1

Direct Comparison of Health Impacts

Respiratory Effects

• Shisha smoking causes significantly worse lung function impairment compared to e-cigarettes, with reduced FEV1 (3.26 ± 0.71 L/s for shisha vs. near-normal values for e-cigarettes) and FVC measurements comparable to traditional cigarette smokers 2
• Both shisha and cigarette smokers demonstrate obstructive airway changes, while e-cigarette users show comparatively higher lung function, though some still exhibit borderline obstruction 2
• Shisha smoking is significantly associated with lung cancer risk 3

Cardiovascular and Inflammatory Markers

• Shisha smokers demonstrate inflammatory profiles similar to cigarette smokers, with elevated white blood cell counts and inflammatory markers 2
• E-cigarette users show lower inflammatory markers (WBC, neutrophils, lymphocytes, monocytes) compared to both cigarette and shisha users 2
• However, e-cigarettes still cause deleterious cardiovascular effects through nicotine, vaporizing solvents, particulate matter, metals, and flavorings 1
• Nicotine from any source contributes to coronary artery disease, atherosclerosis, and aortic aneurysms 1, 4

Acute Cardiovascular Effects

• Shisha smoking causes significant acute rises in heart rate and blood pressure 3
• Long-term cardiovascular effects of shisha remain incompletely established but are concerning given the acute changes 3

Critical Limitations of Both Products

E-Cigarettes Are Not Harmless

• E-cigarettes contain and emit numerous potentially toxic substances beyond nicotine, with highly variable exposure based on product characteristics 1
• Evidence regarding e-cigarette efficacy for smoking cessation is limited, with only moderate evidence from a 2020 Cochrane review showing potential benefit over nicotine replacement therapy 1
• Dual use of e-cigarettes while continuing traditional cigarettes is not associated with higher quit rates 1
• The World Health Organization does not endorse e-cigarettes as cessation aids 5

Shisha-Specific Risks

• Shisha smoking induces nicotine dependency similar to cigarette smoking 6
• Increases risk of infections and has been associated with disease outbreaks in the Middle East 3
• Various forms of cancer beyond lung cancer have been documented, though statistical significance requires further research 3

Youth and Addiction Concerns

• E-cigarette use among youth poses a clear public health threat, with unprecedented increases in use 1
• High-nicotine delivery systems (like JUUL) have increased addiction potential for young people 1
• E-cigarette use is associated with increased odds of adolescents starting combustible cigarettes who had no previous intention to smoke 1

Recommended Approach for Smoking Cessation

First-Line Evidence-Based Treatments

• Behavioral counseling combined with FDA-approved pharmacotherapy (varenicline, bupropion, or nicotine replacement therapy) is the proven approach for smoking cessation 1
• Varenicline is the most efficacious pharmacotherapy, including for people with diabetes 1
• Pharmacotherapy plus counseling improves cessation rates compared to either alone 1

If Patient Insists on E-Cigarettes

• Advise against dual use of both combustible and electronic cigarettes 1, 7
• Establish a clear plan to eventually quit e-cigarettes as well 1
• Monitor for continued nicotine dependence, as trial evidence shows high rates of continued e-cigarette use after intervention phases 1

Clinical Pitfalls to Avoid

• Do not recommend e-cigarettes as a first-line cessation tool—they lack the evidence base of approved pharmacotherapies 1, 5
• Do not characterize e-cigarettes as "harmless" or "safe" alternatives—they pose cardiovascular and respiratory risks 1
• Avoid the misconception that shisha is safer because smoke passes through water—it causes lung function impairment comparable to cigarettes 2, 3
• Screen specifically for all tobacco products including shisha and e-cigarettes at routine visits 1, 7

Bottom Line for Clinical Practice

Neither shisha nor e-cigarettes should be recommended for smoking cessation or harm reduction. 1, 5 While comparative data suggests e-cigarettes may cause less respiratory impairment and inflammation than shisha in the short term 2, both products pose significant health risks including cardiovascular disease, respiratory dysfunction, and continued nicotine addiction 1. Direct patients toward proven cessation methods: behavioral counseling combined with varenicline, bupropion, or nicotine replacement therapy. 1