Water Pipes

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Call To Action

Governments should regulate water pipes and their use in the same ways as all other combustible tobacco products, and the use of water pipe in public places should not be exempted from smoke-free laws.

Percentage of adults currently using water pipe

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 their form of tobacco use is safer 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 be increasing harm by enabling water pipe smokers to inhale smoke deeper into their lungs.

Water pipe smoking is 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 tobacco.

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 who used water pipes: 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.



We calculated the proportion of all tobacco users who engaged in water pipe use. We want to emphasize that women in Middle Eastern countries who are frowned upon for using cigarettes, as they are a form of tobacco typically consumed in public, are more likely to pick up water pipe use. I’m showing that when women choose to smoke tobacco they often use water pipe at a higher rate than their male counterparts. This does not mean that women smoke more water pipe than men, but simply that among those women who smoke, water pipe is disproportionately popular.


Baheiraei A, Mirghafourvand M, Nedjat S, Mohammadi E, Mohammad-Alizadeh Charandabi S. Prevalence of Water Pipe Use and Its Correlates in Iranian Women of Reproductive Age in Tehran: A Population-Based Study. Med Princ Pract. 2012;21(4):340–4.

Khattab A, Javaid A, Iraqi G, Alzaabi A, Ben Kheder A, Koniski M-L, et al. Smoking habits in the Middle East and North Africa: Results of the BREATHE study. Respir Med. 2012 Dec 1;106:S16–24.

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.


(450mL) is nearly equal to the volume of smoke inhaled from an entire cigarette (500mL).



This is a calculation derived from the following exact quote, “A typical 1-hour-long hookah smoking session involves 200 puffs, while an average cigarette is 20 puffs. The volume of smoke inhaled during a typical hookah session is about 90,000 milliliters, compared with 500 to 600 milliliters inhaled when smoking a cigarette.”


US Department of Health and Human Resources. The Dangers of Hookah Smoking. Be Tobacco 2012 [cited 2014 Jul 9].

The promotion of water pipe use is rooted in wilful ongoing misinformation that hookah water can magically clean up tobacco smoke. Nothing could be further from the truth. “WATER… HAS ONLY A SMALL EFFECT ON THE REMOVAL OF TAR AND TOTAL NICOTINE.” –British American Tobacco Research & Development, 1967.


Ma’assel, 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%.


Waterford Cigarettes

In 1966, a new American Tobacco Company cigarette featured a crushable water capsule. The company made claims that they were using the “oldest idea in smoking” (water filtration from a hookah) to enhance the taste of their cigarette. This cigarette debuted as companies used words like “taste” to signal that one cigarette was “healthier” than another.

The American Tobacco Company was willing to leverage the idea that hookahs filtered smoke effectively through water to sell a supposedly safer cigarette. Waterford was a commercial flop.

This is an interesting development when placed in the context of the tobacco industry’s development of several issues.

  1. The industry was willing to utilize the harm reduction angle central to water pipe use, that water works as a smoke filter, to sell cigarettes back in the 1960s.
  2. This was the first “capsuled” cigarette, a technology that has resurfaced today.
  3. American Tobacco Company wanted to link the cigarette to water pipes so they added a picture of what looks like a man drinking directly from a tea kettle to the advertisement.

Names for Water Pipes

English and Native Script and the countries where a name predominates

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