Yes. Hookah (waterpipe, shisha) smoke contains known cancer-causing substances, which are also found in the blood and urine of people who use it [1, 9]. Studies have linked hookah smoking to cancers of the lung, mouth, oesophagus, stomach and bladder [3, 4, 5]; in the Golestan study in north-eastern Iran, people who had smoked a lot of hookah over many years were nearly three times as likely to die of cancer [6]. The belief that hookah is safer than cigarettes is wrong: one hookah session puts more than 100 times as much smoke into the lungs as one cigarette, and the water does not filter this smoke [1, 2, 8].
Key points
- Hookah smoke causes cancer: it contains the cancer-causing substances of cigarette smoke, and the charcoal also produces toxic and cancer-causing substances [1, 2].
- It is linked to several cancers: lung, mouth, oesophagus, stomach and bladder [3, 4, 5].
- The water does not filter the smoke, and fruit-flavoured or "tobacco-free" hookah is not safe either [1, 2].
- One hookah session puts more than 100 times as much smoke into the lungs as one cigarette [2, 8].
- Hookah smoke also harms the people around you [1, 2].
Which cancers does hookah cause?
In a hookah, charcoal is placed on top of the tobacco. Air is drawn over the charcoal and through the tobacco, and the smoke passes through water before it reaches the lungs [1]. This smoke contains known cancer-causing substances such as nitrosamines, combustion products (the same ones found in cigarette smoke), benzene, formaldehyde and heavy metals [1]. Blood and urine tests in people who use hookah show that these substances really are absorbed into the body [1, 9].
In the largest review of the evidence, covering 191 studies from 24 countries, hookah smoking was linked to cancers of the lung, oesophagus, stomach and bladder and to a higher risk of dying of cancer [3]. Another review also found a link with mouth cancer [5]. Most of these studies are small and the quality of the evidence is still low, but they all point the same way: hookah raises the risk of cancer [3].
| Cancer | Increase in risk |
|---|---|
| Lung | More than twice [3, 4, 5] |
| Oesophagus | About 3 times [3, 4] |
| Stomach | About twice [3] |
| Mouth | About 4 times [5] |
| Bladder | About one and a half times [3] |
| Death from cancer | More than twice [3] |
Most of these figures come from studies that compared patients with healthy people, and the quality of the evidence is still low [3].
The Golestan study: hookah in a large cohort in Iran
The Golestan Cohort Study has followed more than 50,000 people aged 40 to 75 in north-eastern Iran [6]. In this study, people who had smoked a lot of hookah over their lifetime (for example, once a day for 28 years or more) died earlier and were nearly three times as likely to die of cancer [6].
In the urine of hookah smokers in the same study, levels of some cancer-causing substances from the smoke were even higher than in cigarette smokers [9]. Another study across several regions of Iran found that the risk of lung cancer was about twice as high in people who smoke hookah every day, and rose with the number of sessions and the years of use [7].
Myths about hookah
| Myth | What the evidence says |
|---|---|
| The water filters the smoke | Even after passing through the water, the smoke still contains large amounts of toxic and cancer-causing substances [1, 2]. |
| Hookah is healthier than cigarettes | This belief is wrong, and hookah is not a safe alternative to cigarettes [1, 2]. A typical one-hour hookah session produces more than 100 times as much smoke as one cigarette, with more nicotine and more carbon monoxide too [2, 8]. |
| Fruit-flavoured, "herbal" or tobacco-free hookah is safe | Smoke from tobacco-free hookah contains the same toxic substances and carbon monoxide; it just has no nicotine [1, 2]. The sweet flavours only make the smoke smoother and more pleasant [1]. |
| Hookah is not addictive | Hookah smoke contains nicotine, and users show signs of nicotine dependence [1]. |
| Smoking hookah with friends now and then does no harm | Hookah smoke reaches everyone around and is a risk for people who do not smoke as well [1, 2]. |
Second-hand hookah smoke
Hookah smoke does not only harm the person smoking. Large amounts of carbon monoxide, very fine particles and cancer-causing substances have been measured in the air around a hookah, coming from both the tobacco and the charcoal [1, 2]. In a review of studies, people exposed to other people's hookah smoke had more wheezing [5]. Babies of mothers who smoke hookah during pregnancy may have a lower birth weight [2, 5]. Do not light a hookah at home, in the car, or near children or pregnant women.
What should I do? One important step: give up hookah and get help
- 1
Set a quit date
Hookah is addictive and giving it up can be hard [1]. Choose a date to stop, and take the hookah and its accessories out of your home.
- 2
Ask your doctor for help
Your family doctor or a stop-smoking service can help with counselling and, if needed, medicines. See the methods that help people quit in How much does quitting smoking lower cancer risk?
- 3
Do not swap hookah for another form of tobacco
Tobacco-free or flavoured hookah also produces toxic smoke [1], and cigarettes are no better. Opium also causes cancer (Does opium cause cancer?).
When should I contact a doctor?
If you smoke or have smoked hookah and have any of these symptoms, see a doctor soon: a long-lasting cough or coughing up blood, difficulty or pain when swallowing, a sore or a white or red patch in the mouth that does not heal, hoarseness for more than a few weeks, blood in the urine, or unexplained weight loss. See the signs in symptoms of lung cancer, symptoms of oesophageal cancer and symptoms of stomach cancer.
Frequently asked questions
How many cigarettes is one hookah session equal to?
There is no exact answer, because it depends on how long the session lasts and how the person smokes. In a review of laboratory studies, one hookah session put more than 100 times as much smoke into the lungs as one cigarette, with more nicotine, tar and carbon monoxide [8]. The US Centers for Disease Control and Prevention also says that a one-hour session produces 100 to 200 times the smoke of one cigarette [2].
Which is worse, hookah or cigarettes?
Neither is safe, and the belief that "hookah is healthier" is wrong [1]. In the Golestan study, both cigarettes and hookah were linked to earlier death and to death from cancer [6]. Because one hookah session contains far more smoke than one cigarette, someone who smokes hookah every day takes a great deal of smoke into the lungs [2, 8].
What if I only smoke now and then, at parties?
The risk rises with how often and for how many years you smoke; in a study in Iran, the risk of lung cancer was about twice as high in people who smoked every day or had smoked for more than 20 years [7]. Smoking less is better than smoking more, but the best thing is to stop completely.
Is hookah addictive?
What about fruit-flavoured or tobacco-free hookah?
I have smoked hookah for years. Do I need any special tests?
Tell your doctor about your hookah use and watch for the warning signs above. If you have also smoked cigarettes, check whether lung cancer screening is right for you: Should I be screened for lung cancer?
Details of the evidence (for physicians)
For physicians
Meta-analyses. Sepidarkish 2025 (191 observational studies, 807,174 participants, 24 countries; mostly case-control): gastric cancer OR 2.11 (1.02 to 4.40), lung OR 2.61 (1.28 to 5.34), bladder OR 1.57 (1.14 to 2.18), oesophagus OR 2.95 (1.36 to 6.40) and cancer mortality aHR 2.57 (2.10 to 3.18); high heterogeneity and low to very low GRADE certainty [3]. Montazeri 2017 (13 case-control studies): lung OR 4.58 (2.61 to 8.03) and oesophagus OR 3.63 (1.39 to 9.44) [4]. Waziry 2017 (50 studies): oral cancer OR 4.17 (2.53 to 6.89) and lung OR 2.12 (1.32 to 3.42); in that review, associations with oesophageal, gastric and bladder cancer were not significant [5].
Golestan Cohort Study. 50,045 people aged 40 to 75, median follow-up 8 years; only 1.1% reported waterpipe use (underpowered analyses). With cumulative use of ≥28 waterpipe-years (duration × times per day): all-cause mortality HR 1.66 (1.11 to 2.47) and cancer mortality HR 2.82 (1.30 to 6.11) [6]. Urinary PAH and VOC biomarkers were higher in waterpipe smokers than in non-users, and the phenanthrene and pyrene metabolites and two VOC metabolites were higher even than in cigarette smokers [9]. IROPICAN (627 lung cancer cases and 3477 controls): overall OR 1.3 (1.0 to 1.7), daily use 2.1 (1.4 to 3.0), more than 20 head-years 2.8 (1.9 to 4.1) and exclusive waterpipe use 2.3 (1.6 to 3.5); the association was significant only for squamous cell carcinoma [7].
Exposure. One waterpipe session delivers 74.1 litres of smoke (38.2 to 110.0) vs 0.6 litres for one cigarette [8]. Compared with cigarette smokers, waterpipe smokers have much greater exposure to CO, greater exposure to PAH, similar exposure to nicotine and lower exposure to tobacco-specific nitrosamines; smoke from tobacco-free products has the same toxicity apart from nicotine [1].
In practice. Record waterpipe use (sessions per day and years of use) in the history as you would for cigarettes, and refer for cessation support.
Related cancer types
References
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Numbers in the text, such as [1], refer to these sources. Sources with a “Study card” button are summarised in the site’s evidence library.
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This page is based on reputable scientific sources and was last updated on 28 October 2026. The content of this website is for educational and informational purposes only and does not replace consultation, diagnosis or treatment by a specialist physician. Consult your treating physician about any treatment decision.
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