Smoking shisha is associated with three main detrimental health effects: cardiovascular damage, infection, and cancer formation. Much of the morbidity and mortality associated with shisha smoking can be attributed to the impairment of the cardiovascular system. It is important to note that in some studies studying the effects of shisha smoking, regular cigarette smokers were not excluded. Therefore, the results observed may have been due to a combined biological effect of both cigarette and shisha smoke.

Shisha smoking has been reported to disrupt the autonomic regulation of the cardiac cycle, by causing an acute reduction in heart rate variability This may be associated with increased susceptibility to arrhythmia, systemic inflammation, and risk of 7 coronary heart disease. A positive association between coronary artery disease and shisha smoking was reported although the study did not demonstrate statistical significance. Interestingly, serum concentrations of high-density lipoprotein (HDL) – cholesterol and Apo lipoprotein (Apo) A-1 were found to be significantly lower in shisha smokers than in non-smokers. Moreover, low-density lipoprotein (LDL) – cholesterol, Apo B, triglycerides, and malondialdehyde were significantly higher in shisha smokers than in non-smokers. Total antioxidant capacity and vitamin C were also found to be significantly lower in shisha smokers than in non-smokers. These findings may implicate shisha smoking as a risk factor for coronary heart disease.

 In a previous study we conducted, systolic blood pressure, diastolic blood pressure, heart rate, and CO levels were all observed to rise significantly after smoking shisha. These results were also observed in studies from Jordan and the United Arab Emirates. The parameters described above were notably higher in shisha smokers, compared with cigarette smokers. Ultimately, in chronic shisha smokers, systolic blood pressure and heart rate remain significantly elevated. People who smoked both shisha and cigarettes were reported to have the highest mean systolic blood pressure and heart rate, across all age groups.

NO, a vasodilator, was found at a significantly higher serum concentration in shisha smokers (34.3 μmol/l) compared with non-smokers (22.5 μmol/l). It was reported that shisha smokers showed impaired vasodilation of the brachial artery in response to shear stress, compared with that cigarette smokers and non-smokers. This impaired vasodilation could potentially lead to vascular remodeling and dysfunction.

Wolfram et al showed that a single shisha smoking session significantly affected platelet function. The induced injury was marked by an elevation of both 8-epi-prostaglandin F2 alpha and malondialdehyde, which are both markers for in vivo oxidation injury. 11-Dehydrothromboxane B2, a parameter of platelet homeostasis, was also found to be elevated after a single smoking session. Interestingly, the study also reported that consistent daily smoking resulted in a persistent longer-lasting oxidation injury. This homeostatic imbalance in shisha smokers may possibly cause platelet aggregation and could increase the likelihood of atherothrombotic cardiovascular events.

There is a substantial risk of infection with herpes, hepatitis, and tuberculosis (TB) after smoking shisha. Often, shisha is smoked in large groups, rather than as individuals. By sharing mouthpieces, various commensal and pathogenic organisms may be transmitted between smokers through saliva. Recently, shisha cafes provide plastic disposable mouthpieces to every customer, which aims to limit the spread of communicable diseases. The risk of infectious disease also increases due to the moist nature of shisha molasses, creating an environment that promotes the growth of many different microorganisms. Lastly, although well-run shisha cafes regularly wash their shisha pipes, the relatively rigid and complicated structure of the shisha apparatus makes it virtually impossible to efficiently wash the internal aspects.

For example, TB may grow and survive on the internal surface of the shisha pipe and water, significantly increasing the risk of transmission. In the Middle East, outbreaks of infectious diseases have been correlated with shisha smoking. Akl et al described two outbreaks in 2010, which revealed a possible association between TB and sharing a shisha pipe.

In a similar way to cigarette smoking, shisha smoking introduces many harmful chemicals and free radicals into the body, many of which have been implicated in cancer development. For example, one study revealed that smoking shisha quadruples the risk of lung cancer when compared to non-smokers. Other studies also reported that there was an association of shisha smoking with bladder cancer, prostate cancer, squamous cell carcinoma, keratoacanthoma of the lip, nasopharyngeal cancer, esophageal cancer, and oral dysplasia. However, these associations were not statistically significant.