The hookah (water pipe or shisha) smoker can inhale the equivalent of 100 or more cigarettes in one session. Cigarettes are usually smoked over the course of 5-7 minutes with the smoker inhaling 8-12 times (0.5/0.6 liters of smoke). Water pipe smoking sessions last much longer: generally 20-80 minutes with the smoker taking 50-200 puffs of 0.15-1 liter each.
The water does not filter out harmful elements and the shisha smoker is exposed to carcinogens and carbon monoxide from the tobacco and the charcoal for much longer periods, all of which makes shisha smoking more, rather than less, hazardous than cigarettes. The level of nicotine can increase up to 250 percent and the cotinine level increase up to 120 percent after just one session of smoking.
Shisha smoking is a communal activity and often the mouthpiece is shared around the group with risk of communicable diseases such as tuberculosis, helicobacter pylori and herpes.