Shisha and Hookah: How They Work, Real Figures and Regulations in France

Shisha holds a place apart in the tobacco landscape. It is seen as sociable, flavoured, almost harmless, and yet the available data tell a very different story. A hookah session lasts between 40 and 60 minutes and involves 50 to 200 puffs, compared with 8 to 12 puffs for a cigarette smoked in 5 to 7 minutes. Over that time, the smoker inhales roughly 125 times more smoke, 25 times more tar, 10 times more carbon monoxide and 2.5 times more nicotine than with a regular cigarette.

The gap between perception and reality is striking. Only 39% of shisha users think the practice is truly toxic, and only one user in ten is considering quitting, compared with 77% of cigarette smokers. In France, nearly one 17-year-old in two has already tried the hookah, and around 20% of 18-year-old secondary school students use it at least once a month.

This article covers the whole subject: how a hookah really works, what recent scientific studies measure, why carbon monoxide is the most underestimated danger, where this five-hundred-year-old practice comes from, what French law says precisely about shisha bars, and how to handle ash and coals properly when you smoke at home. The aim is not to moralise but to give the exact figures and verifiable references that are missing almost everywhere else.

Chicha, Hookah, Shisha: What Exactly Are We Talking About?

All three words refer to the same object, with nuances of usage depending on the region. The term narguilé (hookah) comes from the Persian nargil, meaning coconut, itself derived from Sanskrit. This etymology is not trivial: the first water pipes were made from a hollowed-out coconut serving as a reservoir, extended by a bamboo tube. The word chicha (shisha) derives from the Persian shishe, meaning glass, a reference to the transparent vase that characterises the modern object.

A complete hookah is made up of five distinct elements:

• The bowl, or head, generally made of clay or ceramic, which holds the flavoured tobacco
• The perforated aluminium foil or heat management cup, which separates the tobacco from the heat source
• The charcoal, natural or self-lighting, placed on top, which heats the tobacco without burning it directly
• The stem and the base, where the smoke passes through water before being drawn in
• The hose and the mouthpiece, often shared between several participants

The tobacco used, called moassel or molasses tobacco, generally contains 20 to 30% tobacco, the rest being made up of molasses or glycerine and flavourings. It is this sweet composition that produces the dense, fragrant smoke, and that contributes to the false idea of a mild practice.

How a Hookah Really Works

The principle is often misunderstood. Unlike the cigarette, where tobacco burns directly at a temperature between 700 and 900 degrees, shisha tobacco is not meant to burn. It is heated by conduction and radiation from the charcoal above, at a temperature that theoretically stays between 150 and 450 degrees depending on heat management.

This gentler combustion is precisely what causes the problem. Incomplete combustion produces more carbon monoxide than vigorous combustion. The charcoal itself, which burns throughout the session, becomes a major source of carbon monoxide, heavy metals and carcinogenic compounds that add to those from the tobacco.

Passing through water, often presented as a filtration system, has a very limited effect. Water cools the smoke and retains a fraction of the soluble particles, which makes inhalation less irritating and mechanically lets you inhale more deeply and for longer. But it does not retain carbon monoxide, which is a poorly soluble gas, nor most volatile organic compounds. Inhalation comfort increases while real exposure remains high.

Three aggravating factors come on top in everyday practice:

• Duration: a session lasts three to ten times as long as a cigarette
• Volume per puff: around 500 to 600 ml for a hookah puff against 40 to 75 ml for a cigarette
• Sharing the mouthpiece, which raises a separate health question of transmission of respiratory and oral pathogens

Shisha vs Cigarette: The Exact Figures

The following table gives the orders of magnitude most frequently cited in scientific literature and by public health bodies. They correspond to one full hookah session compared with a single cigarette.

Parameter	Cigarette (1 unit)	Shisha (1 session)	Ratio
Duration of use	5 to 7 minutes	40 to 60 minutes	about x8
Number of puffs	8 to 12	50 to 200	about x10 to x20
Volume of smoke inhaled	reference	125 times more	x125
Tar	reference	25 times more	x25
Carbon monoxide	reference	10 times more	x10
Nicotine	reference	2.5 times more	x2.5
Volume per puff	40 to 75 ml	500 to 600 ml	about x10

The World Health Organization estimates that a single hookah session corresponds, in terms of exposure, to smoking 20 to 30 cigarettes. Some estimates for a full one-hour session suggest the equivalent of 100 to 200 cigarettes in volume of smoke inhaled. These wide ranges are explained by the real variability of sessions: type of charcoal, amount of tobacco, intensity of drawing, actual duration. They all converge on one point: exposure is far greater than, never lower than, that of a cigarette.

One point deserves clarifying because it circulates widely: the tar produced by shisha is no less carcinogenic than that of a cigarette. The concentrations of tar and nicotine in hookah tobacco are comparable to those in cigarette tobacco. It is the way it is consumed, not the composition, that changes the scale of exposure.

What Recent Scientific Studies Say

Research on the hookah has become considerably more structured since 2020, with several large systematic reviews that make it possible to move beyond rough estimates.

A meta-analysis published in 2024 in Nicotine and Tobacco Research compiled 73 studies covering 3,755 participants exposed to hookah smoke, searching PubMed, Embase, Web of Science, CINAHL Plus, PsycINFO and the Cochrane Library up to April 2023. The biomarkers identified cover exhaled carbon monoxide, carboxyhaemoglobin, tobacco alkaloids, tobacco-specific nitrosamines and volatile organic compounds. This review confirms that exposure is measurable and systematic, including among occasional users.

A narrative review published in 2024 on PubMed Central analyses in detail the mechanics of combustion, the associated health risks and the regulatory difficulties specific to this product. It stresses that the hookah largely escapes the regulatory frameworks designed for cigarettes, particularly as regards health warnings, taxation and advertising restrictions.

On the French institutional side, the French National Cancer Institute has published an analysis dedicated to comparing shisha and cigarettes, and Santé publique France carried out the first national survey on shisha consumption patterns, whose data remain the basis for the prevalence estimates used today.

The prevalence figures from this work and from reports by the French Monitoring Centre for Drugs and Addictive Trends are as follows:

• Nearly half of 16-year-old pupils have smoked shisha at least once
• Around 20% of 18-year-old secondary school students use it at least once a month
• In 2017, one 17-year-old in two said they had tried it
• Among young apprentices in 2018, 9% said they smoked shisha, 4% of them exclusively
• Use is mostly occasional: 60% of users smoke between once a month and once a week
• Sessions take place in the evening in 87.2% of cases and at weekends in 84.4% of cases
• The place of use is the home for 48% of users, a shisha cafe for 26%, and friends' homes for 26%

This last point is important for what follows: nearly one use in two takes place at home, in a setting where ventilation, coal handling and ash disposal are entirely up to the user.

Carbon Monoxide, the Most Underestimated Risk

This is the point on which shisha differs most clearly from the cigarette, and the one most users are unaware of. Carbon monoxide is a colourless, odourless gas that binds to haemoglobin about 230 times more readily than oxygen, forming carboxyhaemoglobin and gradually depriving tissues of oxygen.

The measurements recorded in hookah smokers are unambiguous. Carboxyhaemoglobin levels observed average around 10.1% with a standard deviation of 2.5%, and some studies report averages reaching 17.3%. By comparison, a non-smoker in a normal environment is below 2%, and a regular cigarette smoker around 4 to 8%. The first clinical symptoms of poisoning generally appear from 10 to 15%.

A study published in 2024 comparing hookah-related and non-hookah-related carbon monoxide poisonings analysed 111 emergency department visits with a carboxyhaemoglobin level of 10% or higher, between January 2019 and August 2023. A striking result: 73.9% of these poisonings were attributable to hookah exposure. This is therefore not a theoretical risk but a documented reason for emergency visits.

A systematic review of clinical cases published in 2025 in the JMA Journal looked specifically at the behavioural and environmental factors that favour carbon monoxide poisoning and polycythaemia in hookah smokers. The recurring factors identified are sessions in enclosed or poorly ventilated spaces, prolonged duration, use of non-natural charcoal and lighting the charcoal indoors.

The symptoms of early poisoning are easily mistaken for simple malaise: headaches, dizziness, nausea, confusion, a feeling of weakness. This explains why many sessions continue when the first signs are already present. The World Health Organization reminds us that hookah smoke, even after passing through water, contains high concentrations of toxic products including carbon monoxide, heavy metals and carcinogenic chemical compounds.

This issue also ties in with the wider question of involuntary exposure of people in the room, a subject we have covered in detail in our article on the risks and figures of passive smoking.

History and Culture: Five Centuries of Social Ritual

The hookah is not a recent fad. Its trace goes back more than five hundred years, with a debate still open about its exact cradle. The main hypotheses place its appearance in India or Persia, with some researchers also suggesting East Africa.

The first versions were rudimentary: a hollowed-out coconut as a reservoir and a bamboo tube. In India, the object was first used to smoke medicinal herbs before being used for tobacco blends. This medicinal origin partly explains the lasting reputation for mildness that still clings to the practice.

It spread along trade routes. From Persia, the water pipe reached the Arabian Peninsula between the 16th and 17th centuries, then the Ottoman Empire and North Africa. In Turkey it became, in the 17th century, a genuine social institution, at the centre of cafes and salons. The design we know today, with its ornate blown-glass bases and elaborate hoses, owes a great deal to this Ottoman period.

This status as a parlour object brings the hookah close to other smoking accessories designed as decorative pieces as much as functional ones. The tradition of metalwork and engraved glass can be found directly in the aesthetics of Moroccan ashtrays, heirs to the same Mediterranean and Oriental craftsmanship. For those interested in how these objects have evolved, our history of the ashtray traces a parallel path, from utilitarian accessory to design object.

The mass arrival of shisha in Western Europe is much more recent, driven from the 1990s and 2000s by molasses-flavoured tobaccos and the opening of dedicated bars. It is this commercial form, very far from the original domestic ritual, that made shisha a practice of young adults in France.

What French Law Says About Shisha and Shisha Bars

French regulations provide no special status for shisha. It falls under ordinary tobacco law, which has direct consequences, often poorly understood by establishments and customers alike.

Article L3512-8 of the Public Health Code prohibits smoking in places used for collective purposes, except in areas expressly reserved for smokers. Shisha bars are therefore subject to the same framework as other drinking establishments under the Evin law: smoking is in principle prohibited in an enclosed and covered place open to the public.

The smoking room exception exists, but it is strictly regulated:

• The smoking room may occupy at most 20% of the total floor area of the establishment
• No service may be provided in this space, which rules out serving drinks or food
• The space must have a specific mechanical ventilation system and be isolated by closed partitions
• Access is prohibited to minors

In practice, several parliamentary questions in the Senate, notably in 2018 on the regulation of shisha bars, have pointed to a significant gap between the law and practice. The smoking area frequently takes up the whole establishment, drinks are served there, and the admission of minors has been widely documented. On this last point, Tabac Info Service reminds us that the sale of tobacco products to minors is prohibited without exception, which includes hookah tobacco.

For use at home, no specific restriction applies beyond the general rules on neighbours and co-ownership. Using a hookah on a balcony or building terrace may nevertheless conflict with the co-ownership rules, a subject we detail in our article on the right to smoke on a balcony in a co-owned building. The general framework applicable to public spaces is covered in our guide to the ban on smoking in public places.

Handling Ash, Coals and Residues Properly at Home

Since nearly half of sessions take place at home, the practical question of residue management arises concretely. A hookah session produces three types of waste that do not behave the same way: the fine tobacco ash, the partially burnt coals, and the used water from the base, loaded with residues.

The coals are the critical point. A hookah coal stays at a temperature of several hundred degrees well after the end of the session, and it can remain glowing at its core while its surface looks extinguished. Throwing it in an ordinary household bin is a real fire risk, comparable to the one we document in our article on the fire risks of cigarette butts.

A few simple rules reduce the risk:

• Always put out coals in a dedicated metal container, never directly in a bin bag
• Wait for them to cool completely, which takes longer than you might think, often 20 to 30 minutes
• Never place a coal on a wooden, plastic or fabric surface, even briefly
• Do not light the coals indoors: this step produces a significant amount of carbon monoxide
• Do not pour the water from the base down a kitchen sink, as it contains tarry residues that clog the pipes

The choice of container matters more than you might think. A glass or thin ceramic container can crack under thermal shock. A stainless steel ashtray or a solid metal model copes easily with the residual heat of a coal and is easy to clean of molasses residues, which are much stickier than cigarette ash. For use in the living room, a large-capacity tabletop ashtray prevents overflow over a long session, and a closed ashtray limits the spread of fine ash and the resuspension of odours between uses.

For outdoor sessions, which are by far the most advisable setup from a ventilation point of view, a stable, weighted outdoor ashtray prevents tipping over and withstands the weather. Finally, if you use natural coals that need a strong flame to light, a torch lighter delivers a flame powerful and directional enough to start combustion without special equipment, which is still cleaner than lighting on a cooker hob.

Regular cleaning of the whole set also matters. Molasses leaves a film that quickly turns into a stubborn deposit. The principles detailed in our guide on how to clean an ashtray properly apply directly to the containers used for hookah residues, with particular attention to degreasing.

Frequently Asked Questions About Shisha and Hookah

Is shisha less dangerous than cigarettes because the smoke passes through water?
No. Water cools the smoke and retains a small fraction of the soluble particles, which makes inhalation more comfortable. It filters neither carbon monoxide, which is poorly soluble, nor most volatile organic compounds. The added comfort even encourages deeper and longer inhalation.

How many cigarettes does a shisha session represent?
The World Health Organization uses an equivalence of 20 to 30 cigarettes per session. Estimates for a full one-hour session suggest 100 to 200 cigarettes in volume of smoke inhaled. The range is wide because sessions vary greatly in duration, drawing intensity and type of charcoal.

Do nicotine-free tobacco or steam stones remove the risk?
They remove the nicotine intake and therefore the addictive dimension linked to that molecule, but not the carbon monoxide, which comes largely from the charcoal and not from the tobacco. The risk of carbon monoxide poisoning remains as long as a coal is burning in an enclosed space.

Can you smoke shisha in a bar in France?
Only in a compliant smoking room, that is, an enclosed space of less than 20% of the establishment's floor area, mechanically ventilated, with no service whatsoever and closed to minors. In practice, many establishments do not comply with this framework. Use on an open terrace falls under the rules applicable to ordinary terraces.

What are the signs of carbon monoxide poisoning during a session?
Headaches, dizziness, nausea, confusion, muscle weakness, sometimes ringing in the ears. These signs are often wrongly put down to simple malaise or the effect of nicotine. If in doubt, step out into fresh air immediately, ventilate the room thoroughly and seek medical advice if symptoms persist.

How long does it take for a hookah coal to cool completely?
Allow 20 to 30 minutes in a metal container in the open air, longer if the coal is thick or if several coals are grouped together. A coal with a grey surface can remain glowing at its core. Never transfer it to a bin before it has cooled completely.

Does sharing the mouthpiece pose a health problem?
Yes, regardless of the tobacco. Sharing a mouthpiece exposes you to the transmission of respiratory and oral pathogens. Individual disposable or personal mouthpieces are the only practical answer to this risk, and they have become the norm in reputable establishments.

Is shisha addictive?
Yes. Hookah tobacco contains nicotine, and exposure per session is greater than from a cigarette. The occasional, social nature of the practice masks this dependence: only one user in ten is considering quitting, compared with 77% of cigarette smokers, which reflects a far lower awareness of the risk than reality justifies.

Key Takeaways

Shisha is not a mild version of the cigarette. A session exposes you to about 125 times more smoke, 25 times more tar and 10 times more carbon monoxide, with carboxyhaemoglobin levels measured at around 10 to 17% in users. Carbon monoxide from the charcoal is the most concrete and immediate risk, behind nearly three quarters of the poisonings documented in some recent hospital series.

If you smoke the hookah at home, two habits really make a difference: ventilate widely or go outside, and handle the coals in a dedicated metal container until they have cooled completely. To equip your smoking area properly, discover our selection of metal, stainless steel and ceramic ashtrays, designed to withstand heat and clean up effortlessly.