Shisha and the Primary Care Blind Spot

Shisha smoking is increasingly being flagged as an overlooked public health issue in the UK, with experts warning that its impact is often underestimated

CREDIT: This is an edited version of an article that originally appeared in BMJ Group

While cigarette smoking has been the focus of decades of regulation, public health campaigns and clinical intervention, shisha (also known as hookah, narghile or hubble-bubble) has largely remained outside of that spotlight. This is despite its growing popularity, especially among younger adults and within certain communities. With close to 1,000 shisha cafés operating across the UK – and a significant concentration in major cities – its use is far from niche.

The Visibility Problem in Primary Care

For practice managers, this presents a subtle but important challenge. Many patients who regularly smoke shisha do not necessarily identify as “smokers” in the traditional sense. As a result, they may not disclose their usage during consultations, meaning risk factors can go unrecorded and unaddressed. This creates a gap in both patient records and preventative care.

Understanding the Risk Profile

From a clinical perspective, shisha smoking carries its own distinct risk profile. A single session can last up to an hour, exposing users to significant levels of toxins – often far exceeding those of an occasional cigarette. The way shisha is consumed also introduces additional concerns, including prolonged exposure to smoke, the use of charcoal as a heat source, and the sharing of mouthpieces, which can increase the risk of infection transmission.

Operational Implications for GP Practices

For GP practices, this raises important operational and patient engagement considerations. How is smoking status being captured? Are teams asking the right questions to identify non-cigarette tobacco use? And are existing smoking cessation pathways equipped to support patients who may not see their behaviour as harmful?

The Role of Regulation

The proposed Tobacco and Vapes Bill, currently progressing through Parliament, could mark a turning point. By introducing greater consistency across tobacco products, including potential regulation of flavoured tobacco and licensing requirements, it may help bring shisha more firmly into the regulatory framework.

However, legislation alone is unlikely to be enough. Experts argue that meaningful change will require more targeted, culturally aware public health campaigns, alongside support that reflects how and why different communities engage with shisha.

For practice managers, this is an opportunity to take a more proactive approach. Reviewing how lifestyle risks are recorded, ensuring staff are aware of the differences in tobacco use, and adapting patient communication strategies can all help close the gap. Shisha smoking may not present in the same way as traditional tobacco use, but its impact is real. Ensuring it is visible within primary care pathways will be key to addressing it effectively.