Hookahs are traditionally ornately decorated. They have a very distinctive appearance, and bear similarities to the ritual use of the American Indian peace pipe. Relative to other methods of smoking tobacco, hookah smoke is considered smoother and more flavorful. The quantity of smoke inhaled at one time is also much greater. Shisha smoking is generally believed to be less damaging to health than cigarettes. Research has shown that since the tobacco is being heated (as opposed to burned), fewer carcinogens are produced in the smoke.

A recent review published in the medical journal Pediatrics states that the concentration of cancer-causing and addictive substances in water-pipes can be higher than those found in cigarettes, the heat involved being sufficient to generate carcinogenic nitrosamines, and the smoldering charcoal adding carcinogenic hydrocarbons as well as heavy metals to the smoke.

The passage of the smoke through the water does not remove any toxic compounds from the smoke. Ironically, use of the hookah may increase the smoker`s toxic exposure, in that studies have shown that the typical hookah smoker spends more time per episode of smoking than do other smokers, presumably because the smoke is less immediately harsh or irritating.

A study of Egyptian couples found an association between water-pipe smoking and infertility.

Hookah smoking has recently become popular in the United States among people not of Middle Eastern origin, especially in the college and university setting, and is often smoked by those who don`t normally smoke cigarettes or cigars.