Shisha : Nigeria

Shisha

Shisha smoking, a form of tobacco smoking where flavoured or unflavoured tobacco is combusted using charcoal or briquettes and the tobacco smoke is passed through water or other liquids before it is inhaled,

is an increasing public health concern.

It is growing, with an alarmingly high prevalence among young people such as students in high school and tertiary education.

This page provides information on the health risks associated with shisha smoking in Nigeria. It also provides Nigeria-specific information on the prevalence of shisha smoking, the age of initiation of shisha smoking, most common locations for shisha smoking, reasons for smoking shisha, and factors associated with shisha smoking. This information is mainly based on our primary study conducted as part of the TCDI program in Nigeria (hereafter referred to as the Development Gateway Shisha Study (DGSS).

Our study included a cross-sectional survey of 611 current shisha smokers and 667 shisha non-smokers, and qualitative interviews with 78 current shisha smokers. This is the largest study of its kind in Nigeria and covers general- population adults (aged 18 years and above) across all six geopolitical zones. The qualitative study was conducted in 13 states while the quantitative study was conducted in 12 states (two states from each of the six geopolitical zones in Nigeria, i.e.,the North-East, North-West, North-Central, South-East, South-South and South-West, plus the FCT). The quantitative data is available here and the qualitative data is available here. For more information on the results of this study, please download the factsheet here.

Shisha is also referred to by other names, such as water-pipe, hookah, narghile, or hubbly bubbly.

In Africa, even though data on shisha smoking are very minimal,

studies have shown that it is growing rapidly among youth. Some studies have reported prevalence rates as high as 26% to 40% among youth in countries like Rwanda,

Uganda,

and South Africa.

In 2021, the global shisha tobacco market was valued at ~USD 880 million and trends show that it will reach ~USD 1.52 billion by 2029.

This page also incorporates information from other studies on shisha smoking in Nigeria. These studies were mostly focused on specific demographic groups such as secondary school and University students,

health care professionals,

nightclub patrons,

and small groups of people recruited at their homes or shisha smoking places.

The page also discusses COVID-19 risk in relation to shisha smoking.

Shisha smoke is toxic: it contains carcinogens (i.e., substances that can cause cancer) and other toxicants such as nitric oxide and heavy metals.

Shisha smokers are exposed to high levels of carbon monoxide from the burning charcoal.

Although shisha smokers have a significantly lower exposure to some carcinogens, such as tobacco-specific nitrosamines, compared to cigarette smokers, they have a significantly higher exposure to carbon monoxide and to carcinogens such as polycyclic aromatic hydrocarbons.

They are also exposed to similar levels of nicotine as cigarette smokers.

Sharing of the shisha mouthpiece can also lead to the transmission of communicable diseases such as tuberculosis and hepatitis A.

Shisha smoking is significantly associated with several health conditions, such as:

lung, oral, oesophageal, gastric and urinary bladder cancers,
cardiovascular disease,
chronic obstructive pulmonary disease,
periodontal disease,
low birth weight,
stroke,
infertility, and
impaired mental health.

Evidence from Nigeria suggests that the prevalence of shisha smoking is high particularly among young people.

An analysis of data from the The 2018 Nigeria Demographic and Health Survey (NDHS) indicated that 0.2% of Nigerians aged 15 to 59 years old smoked shisha, with no difference between men and women.

However, studies among secondary school pupils and university students have reported high prevalence rates of current shisha smoking ranging from 3% to 7%.

14 One of these studies also reported a higher current shisha smoking prevalence among males (9%) than females (5%).

Another small study of 78 physicians, dentists and surgeons in Northwest Nigeria found that 4% were current shisha smokers.

In another study of 633 nightclub patrons in Southwest Nigeria, about 7% were current shisha smokers.

In the DGSS, about 13.5% of current shisha smokers smoked it daily, while the remaining 86.5% smoked it less than daily. More male than female current shisha smokers smoked it daily or on most days of the week (28.6% vs. 10.7% respectively). Other studies in Nigeria have reported 40% to ~80% of shisha smokers being daily shisha smokers.

In the DGSS the mean age at initiation of shisha smoking was about 22.6 years, with about 9 out of every 10 current shisha smokers initiated by the age of 30. Other studies in Nigeria found that the majority of shisha smokers started smoking it when they were aged 16 years or above.

Age of initiation of shisha smoking

Data source: Development Gateway Shisha Study

The most commonly reported places of shisha smoking initiation and continued use are bars, clubs, lounges, cafés or restaurants.

In the DGSS 58% of shisha smokers initiated and mostly smoked it at bars, clubs, lounges, cafés or restaurants, and at parties or other celebrations, usually in the company of friends. Only ~23% reported mostly smoking shisha at their own homes.

… I started using shisha at the club…., here in Nigeria shisha is a common thing at the club…
Ebonyi Female 30 High SES Rural

Usual places for smoking shisha

Other places

Other people's home

Home

Club; bar; lounge; cafe

Data source: Development Gateway Shisha Study

Other studies in Nigeria reported similar results.

This is despite the fact that tobacco smoking in indoor and outdoor public spaces for the service of consumption of food/drink, including cafeterias, restaurants, and any other place for public refreshment and hospitality, is prohibited. In the DGSS, the timing of activities in clubs meant that shisha was commonly used in the evening, at night or on weekends. Only a few smokers occasionally smoked it in the morning or during the day, or during the week when they have to go to work.

The main reasons cited by shisha smokers in the DGSS include flavours, pleasure, perceived social benefits, curiosity about shisha, using shisha smoking as a coping mechanism for emotional situations or psychological problems, perceived physical and neurological benefits, and availability.

Self-reported reasons for smoking shisha

Data source: Development Gateway Shisha Study

Flavours

Flavoured shisha plays a significant role in shisha initiation and continued use.

About 30% of shisha smokers in the DGSS cited flavour-related reasons (e.g., shisha’s smell and taste) as one of the main reasons for starting and continuing shisha smoking.

“…. I just like the flavour. It is the flavour that just pushes me into taking it….” Kano, Female, 33, Low Socioeconomic status (SES), Urban

“The smoke that you blow out has a good scent. So, you will not perceive anything as if you smoke anything. That means that you yourself will even like it because of the flavour that you blow out. You will enjoy it”. Rivers, Male, 26, High SES, Urban

65% of the respondents reported that they always smoked flavoured shisha, whilst 32.9% sometimes used flavoured shisha, with only 2.5% reporting never using flavoured shisha. Other studies in Nigeria have also reported flavours as one of the main reasons for shisha smoking.

Pleasure

About 30% of shisha smokers in the DGSS reported that they smoked shisha for fun, pleasure, and excitement. The majority (73%) of shisha smokers reported being in a good mood when they used shisha for the first time and many found smoking shisha enjoyable and fun.

“I don’t really smoke shisha to get high, I just smoke shisha for the fun of it.” FCT, Male 50, High SES, Urban

In another study conducted in Northwest Nigeria, 40% of the shisha smokers reported pleasure as the main reason that they smoked shisha.

Perceived social benefit

Shisha smoking is often a group behaviour. In the DGSS, 22% of shisha smokers cited shisha smoking by friends and family members, or peer pressure as reasons for shisha smoking. Shisha smoking by friends played a significant part in shisha initiation and continued use: for 20% of shisha smokers this was one of the main reasons for smoking shisha. The majority (72%) reported that they typically smoked shisha with other people, and this was usually with friends. Only 13.2% reported that they typically smoked shisha alone.

“You take more when you are with friends, why will you take shisha when you are alone?” Rivers, Male, 32, High SES, Urban

Using shisha also provided some participants with the opportunity to gain some measure of social acceptance or a sense of belonging, especially in social gatherings like parties, night clubs and bars.

“I just made up my mind, I want to try it, let me not be left alone, I want to be among them too”. Plateau, Female, 33, High SES, Rural

The vast majority of shisha smokers agreed that shisha is cool and trendy (88.1%), that shisha smoking is gaining popularity and many of their friends are smoking shisha (83.5%), and that stylish persons use shisha (76.1%).

Other studies in Nigeria also cite peer pressure, the need to belong, and the perception that it is cool and trendy as some of the main reasons for using shisha.

Shisha smoking is also perceived to be a symbol of high social class when compared to cigarettes,

as demonstrated by one respondent:

“Let me tell you something about using Shisha and cigarettes. There’s much difference. Even class. There are classes of people in the society you won’t see them with cigarettes, but they take Shisha. So, cigarette everybody can afford it. Ten-naira, twenty-naira, fifty naira. But not Shisha, you can’t buy shisha with fifty naira, or twenty naira or hundred naira. It costs money” Adamawa, Male, 45, High SES, Urban

The price of shisha was viewed as prohibitive when compared to cigarettes. However, participants revealed strategies that they used to lower the costs, for example, owning your own paraphernalia so the only additional costs are the tobacco (flavoured or unflavoured) and the coals. Quite commonly, friends or acquaintances also split the cost of shisha at public locations.

Curiosity about shisha

For 20% of shisha smokers in the DGSS, one of the main reasons for smoking shisha was curiosity about the product. In the qualitative interviews, participants, especially the youth, indicated shisha initiation was often due to curiosity about shisha after having seen others smoking it:

“….I used to see people take shisha, do you understand? I am amazed by what they do, so one day, I decided to give it a try to know how taking it feels, and when I did, I enjoyed it.” Gombe, Female, 24, High SES, Urban

Coping mechanism for emotional situations

In the DGSS, some shisha smokers (13%) reported that they smoked shisha when they were sad or stressed or to help them cope with challenging life situations.

“….whenever I take shisha I think I feel relieved, maybe if I’m stressed up or maybe I’m thinking about something or maybe I’m having a bad day. I think if I take shisha I will feel relieved because it will ease me from so many things like stress, and the rest and before you know it maybe I can doze off or sleep….” Kogi, Male, Older Adult, High SES, Rural

At least half of current shisha smokers in the DGSS agreed that shisha calms them down when they are stressed (66.8%) and when they are upset (65.9%). 49.7% of current shisha smokers reported being able to concentrate better after smoking shisha. In other studies, 24% noted that shisha smoking made them forget about worries and 22% noted that smoking shisha relieved stress.

Other studies have also reported that some participants mentioned that shisha provided relief from feelings of depression, and helped them relax and forget their worries.

However, there is mounting evidence from cigarette smoking studies showing that, contrary to these perceptions or beliefs, tobacco smoking:

can increase anxiety and tension,
27
can increase the likelihood of developing depression when compared to those who do not smoke tobacco (by 54% to 132%),
28
and
cessation can lower levels of anxiety, stress and depression, and improve mood and quality of life.
29

Perceived physical and neurological benefits

About 5% of shisha smokers in the DGSS reported that they smoked shisha because it made them feel strong, more agile, it made them high, or it helped them think, sleep, keep awake, feel warm when it is cold, or manage their appetite.

“…. it makes me more agile; it gives me morale which I need for the kind of job that I am doing” FCT, Male, 27, Low SES, Rural

Availability

Although less than 1% of the shisha smokers in the DGSS survey cited availability as one of their reasons for use, during the qualitative interviews many shisha smokers said that shisha was easily available, including to those who are under the age of 18 years old. This was viewed as a problem by some of the respondents:

“…. is it from World Health Organization or government that the usage of tobacco is from 18 years and above…. see some boys of 14 – 15 years taking tobacco and nothing, nobody talks to them, nobody educates them on the effect”. Ebonyi, Male, 34, Low SES, Urban

“These substances are all over the place, I wish the government could control them, and be more active in controlling the use, because young lads, even lads that are not up to 18 are already, you know, are sucked in this activity. I wish they could be more conscious about it. But I want to believe there is no control in my community, there is no control, there are these substances all over the place,…. it is all over the place ….” Oyo, Male, 33, High SES, Urban

When asked about where they usually buy shisha, 25% of shisha smokers in the DGSS mentioned clubs, bars, lounges, hotels, cafés or restaurants, 18% mentioned convenience stores, mini-markets or produce markets, 15.5% mentioned smoke shops or tobacco specialty stores, and 14.5% mentioned supermarkets. In addition to the places mentioned above, other studies have reported that shisha is also readily available in pharmacies or online.

The DGSS found an association between the following factors and current shisha smoking status: age, cigarette smoking, alcohol consumption, and shisha smoking among family members or close friends (Table can be found here).

Other studies in Nigeria have reported a relationship between being a current shisha smoker and gender, education, place of residence, the use of other tobacco products, the use of electronic cigarettes, and knowledge about shisha.

Age

In the DGSS, older adults were less likely to be current shisha smokers compared to younger adults. An increase in age by one year decreased the odds of being a current shisha smoker by 9%. Other studies in Nigeria have not found this relationship,

but this could be because they were conducted among specific populations (such as secondary school and university students, or nightclub patrons) where there could have been less variation in age.

Gender

Almost all studies conducted in Nigeria (including the DGSS) found that females are as likely to be shisha smokers as males.

Only one study among medical and dental university students suggests that males are more likely to be shisha smokers than females.

This is different from cigarette smoking, where currently available evidence has consistently reported that males are more likely to smoke than females.

In the DGSS, although shisha smokers reported that any kind of tobacco smoking was generally not socially acceptable in Nigeria, about 80% of shisha smokers agreed that shisha smoking was more socially acceptable than cigarettes, and 90% agreed that females were more comfortable taking shisha than cigarettes.

Education status

There was no evidence of an association between educational status and shisha use in the DGSS. Another study in Nigeria reported similar results.

Place of residence

In the DGSS, there was no evidence of an association between being a shisha smoker and living in an urban or rural area.

Stress, anxiety and depression

In the DGSS, those who screened positive for possible generalised anxiety disorder had 40% lower odds of being current shisha smokers than those who screened negative. There was no evidence of an association between being a shisha smoker and screening positive for possible major depressive disorder, or perceived stress levels. Another study in Nigeria did not find an association between shisha smoking and anxiety.

These results are contrary to international studies that have established an association between tobacco use with high levels of perceived anxiety as well as stress or depression.

Use of other tobacco and nicotine products

Overall, studies in Nigeria have consistently found that those who use other tobacco products are more likely to be shisha smokers than those who do not. In the DGSS, the odds of being a current shisha smoker was six times higher among those who smoked cigarettes than those who did not. Similarly, other studies in Nigeria have reported that being a current cigarette smoker, having ever been a cigarette smoker, or having a history of poli-tobacco use significantly increases the odds of being a shisha smoker five-, thirteen- and two-fold respectively.

Only one out of the five studies identified that have looked at this relationship in Nigeria did not find it, and this was conducted among medical and dental students.

In the DGSS, about 23.6% of current shisha smokers were also current cigarette smokers, with more males (27.6%) than females (10.4%) reporting being both current shisha and cigarette smokers. 40% of these reported that they always or sometimes combine shisha smoking with cigarette smoking. Other studies in Nigeria have reported 30% to 90% of shisha smokers also being users of other tobacco products.

One study in Nigeria that has looked at the relationship between a history of using electronic nicotine delivery systems, otherwise known as e-cigarettes, and shisha use found that those with a history of using these products were 6 times more likely to be shisha smokers.

Alcohol consumption

The DGSS found that those who were current alcohol consumers were 3.5 times more likely to be current shisha smokers than those who currently did not drink alcohol. This finding is in line with other studies in Nigeria, which found that those with a history of alcohol consumption were 5.5 times more likely to be shisha smokers.

In the DGSS survey about 67.3% of current shisha smokers were also current alcohol consumers. The majority (65.7%) of those who were both current shisha smokers and current alcohol consumers always (35.1%) or occasionally (30.6%) smoked shisha while drinking alcohol. In addition, 44% reported that their shisha smoking levels increased when they were co-consuming shisha and alcohol, whilst only 23% reported a decrease.

“It’s normal to drink while smoking Shisha, the aim is just to get high to get tipsy. So when you are smoking Shisha there’s always a glass of drink on the table. You always have to sip your drink and take your Shisha. That’s when it works more. I have never really taken Shisha alone. I don’t even know if taking Shisha alone makes someone tipsy but mixing it with alcohol takes you to another level” Edo, Male, 40, High SES, Rural

“Well, it makes me want to increase it. Because the more you drink, the more you want to smoke” Gombe, Male, 32, Low SES, Rural

This is similar to what has been observed by other studies on the co-consumption of shisha and alcohol.

Shisha smoking among family members

Having family members who use tobacco has long been established as a significant factor in influencing individuals, especially young people, to use tobacco. Findings from the DGSS suggest that having at least one family member who also smokes shisha doubles the likelihood of being a current shisha smoker compared to not having any family members who smoked shisha. Another study, conducted among university students in Oyo State, found that the odds of being a shisha smoker was 94 times higher among those who had a sibling who smoked shisha than among those without shisha-smoking siblings.

In the DGSS, about 3 out of every 10 current shisha smokers reported having shisha smokers as family members. Some shisha smokers had been introduced to shisha smoking by family members.

“Since when my elder sister came back from [country], she used to take the shisha in our room and eventually she taught me, and I began to take shisha” Female, 23, Low SES, Kano, Urban

Another study, among current shisha smokers in Northwest Nigeria, found that approximately 70% had at least one family member who also smoked shisha.

Having close friends who also smoke shisha

In the DGSS, those with one close friend who smoked shisha were 21 times more likely to be shisha smokers than those without a shisha-smoking friend. Those who had two or more close friends who smoked shisha were 80 times more likely to be shisha smokers than those without any shisha-smoking friends. Almost all current shisha smokers (97.1%) reported having shisha smokers among their closest friends. In addition, most shisha smokers had started smoking shisha after friends introduced them to it and continued using shisha with friends.

“You know these things about peer group influence where you hang out with friends and all that, you can go to 1 or 2 or 3 occasions before you know it, apart from drinking, this one is on the table and when you see others taking it, you like to now engage to see what is in these things so that was how I started” Male, 32, High SES, Anambra, Urban

Another study in Nigeria, among medical and dental students, has also reported similar results, with those with close friends that smoke shisha being 26 times more likely to be shisha smokers than those without.

In addition, 64% of shisha smokers had been initiated to shisha smoking by friends.

Additional evidence from Nigeria reports 30% to 93% of shisha smokers having at least one friend who also smokes shisha.

Unawareness of shisha health risks

In a study among university students in Rivers State, Nigeria, those with poor knowledge of the constituents and health effects of shisha were four times more likely to have smoked shisha.

Unfortunately, knowledge of the harmful effects of shisha smoking is still low in Nigeria.

In one study, only 6% of shisha ever-smokers had good knowledge of the constituents and health effects of shisha,

whilst others have reported a low level of knowledge on shisha constituents and the specific health impacts of shisha smoking.

In the DGSS, less than half (46.1%) of current shisha smokers believed that shisha smoking causes serious illness, and only about half (54%) believed that shisha smoking affects nonsmokers who are in the vicinity of those smoking shisha. Only 43% believed that shisha contains a significant amount of tobacco. In fact, most of the current shisha smokers (66.0%) perceived shisha to be less harmful than cigarettes. Some participants had stopped smoking cigarettes but continued to smoke shisha for this reason.

“Well, I stopped smoking cigarettes because it is harmful to the system. These smokers are liable to die young, I don’t want to die young [smiles] and I smoke tobacco, but I do not smoke cigarettes” Gombe, Male, 32, Low SES, Rural

The following factors contributed to these beliefs:

The tobacco-control laws and regulations are currently not applied to shisha in the same way that they are to other tobacco products. For example:

shisha pots or paraphernalia do not have written or pictorial health warnings.

In the DGSS, very few (16%) shisha smokers reported seeing health warnings on shisha tobacco packages, charcoal, or the shisha pots in the 30 days preceding the survey.

“I have been seeing some guidelines about tobacco but I have never seen any guidelines about shisha. Like in tobacco you know, we also see it on the packet and posters that smokers are liable to die young and I have never seen any in shisha, that’s what makes me want to continue to be taking shisha.” Adamawa, Male, 30, High SES, Urban

Shisha smoking is allowed in places where cigarette smoking is prohibited:

“…..it’s [shisha] not offensive to the next person around me that doesn’t take it [shisha] and I’ve got to a place where they don’t allow people inside the hall to smoke cigarettes, but I was smoking Shisha. Shisha was allowed but cigarettes were not allowed. So that – that kind of love for it, even for the people that don’t take it makes me enjoy it the more” Rivers, Male, 34, High SES, Urban

While the awareness of tobacco-control laws and regulations was generally poor (only 39% of current shisha smokers were aware of the law or of the regulations generally governing tobacco use in Nigeria), the situation was even worse for shisha, as only about 13.0% reported knowing of any laws or regulations on shisha use in Nigeria.

“There is no regulation to it [shisha]. The only regulation that someone can understand is for instance, the federal government wrote something about cigarettes on the pack, warning that smokers are liable to die young.” Adamawa, Male, 29, High SES, Semi-Urban

Shisha flavours give the perception that shisha is safe both to the smoker and to non-smokers who may be exposed to secondhand smoke.

“Shisha, the flavour, the smoke of shisha does not disturb people like cigarettes. So, anybody, be you Muslim, Christian, or whatever you believe in., shisha smoking does not downgrade whoever smokes it. It’s a thing of choice.” FCT, Male, 50, High SES, Urban

“Because the flavour is not harsh. The flavour at least smells nice. Yes, the flavour smells nice. It will not affect someone that is not taking it.” Kano, Female, 22, Low SES, Urban

The media does not present the negative health impacts of shisha smoking in the same way that it does for cigarette smoking. There is also a widespread portrayal of shisha as an acceptable behaviour, rather than a harmful one, on social media sites like Facebook, Twitter, Instagram, and YouTube, which signals that shisha smoking has been normalised in the society. Social media has been reported by different studies as one of the factors that influence the youth to start smoking shisha. In a study among university students in Southwest Nigeria, the tendency to smoke shisha was stronger among Nigerian youth with a high exposure to pro-smoking social media messages relating to shisha.

Shisha smoking has comparable health risks and burdens to cigarette smoking. Shisha smoke contains high levels of toxins, including carbon monoxide, metals and substances that can cause cancer.
34
In comparison to a single cigarette, smoking shisha for “one session” delivers 25 times the tar, 125 times the smoke, 2.5 times the nicotine, and 10 times the carbon monoxide.
35
Both shisha and cigarettes are addictive, and they have been found to generate nicotine dependence.
36
Shisha smoking has many of the same health risks as cigarette smoking. Even worse, people who use shisha have a higher burden of atherosclerotic disease resulting from greater use, greater exposure, or greater toxicity of water pipe smoke than cigarettes.
37
It is empirically established that both shisha and cigarettes pose a negative health impact to those exposed to secondhand smoke.
38

During the COVID-19 pandemic, studies showed that shisha smoking has detrimental effects in COVID-19 patients.

Shisha use has a high risk of COVID-19 transmission because the pipe mouthpiece is shared.

A study done in Iran reported that, among 474 COVID-19 (SARI) patients, 21% had ever smoked shisha. Out of the 211 PCR-positive patients, 19% were shisha ever-smokers. Shisha smokers were 3.9 times more likely to need ventilation therapy, compared to shisha non-smokers.

Shisha use increases the risk of contracting COVID-19 because:

Shisha is usually smoked in a social setting, such as pubs and clubs where adequate social distancing may not be possible;
The shisha-pipe mouthpiece is passed from one person to another which can increase the risk of COVID-19 transmission;
Shisha smoking can also cause inflammation in the body, which can worsen the symptoms of COVID-19.

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Health risks of shisha smoking

Prevalence of shisha smoking

Age of initiation of shisha smoking

Most common locations for shisha smoking

Reasons for smoking shisha

Factors associated with shisha smoking

Shisha smoking cessation

Shisha vs Cigarettes: Separating Facts from Fictions

Covid-19 and shisha use

References