Smoking, naswar and shisha

This page covers three ways of using tobacco: cigarettes (bidi included), naswar, which goes in the mouth and is never lit, and shisha, also called a waterpipe or hookah.

The Pakistan Menopause Society's 2026 recommendations put all three in a single row of the table on risky substances (Table 7), with a note for doctors about Pakistan: naswar is common in Khyber Pakhtunkhwa, and shisha is often seen as the less harmful choice. Their advice is to address both.

So if you have heard that shisha is gentler because the smoke passes through water, or that naswar does not count because nothing is lit, the Pakistan Menopause Society still puts both in the same row as cigarettes.

On menopause symptoms

The NHS website says not to smoke, because smoking can make menopause symptoms worse. It lists smoking among the possible triggers for hot flushes and night sweats, alongside spicy food, caffeine, hot drinks and alcohol.

The Pakistan Menopause Society's recommendations go further on what stopping does. They say quitting cigarettes, naswar or shisha reduces hot flushes and night sweats, improves bone density, and lowers the risk of heart disease and cancer (Table 7).

On bones and the heart

Among its ways to protect against weak bones, the NHS website lists stopping smoking and cutting down on alcohol. Our page on bone health has the rest.

The Pakistan Menopause Society notes that the average age of menopause in Pakistan is lower than among white women. Its Table 7 says stopping tobacco lowers the risk of heart disease. See heart health.

On smokeless tobacco and shisha

The NHS page on paan, bidi and shisha says tobacco you do not smoke, including paan, betel quid and chewing tobacco, is not a safe way to use tobacco: it causes cancer and can be as addictive as smoking. It links smokeless tobacco to a higher risk of mouth cancer and cancer of the food pipe. That page does not name naswar, so ask your doctor how its warnings apply to it. See also oral health.

On shisha, the same NHS page says smoking cigarettes, bidi or shisha raises the risk of cancer, heart disease and breathing problems, and that waterpipe smoke contains cancer-causing chemicals and toxic gases such as carbon monoxide, as cigarette smoke does.

The NHS website points to expert help from a stop smoking adviser as the most effective way to quit smoking and tobacco. Free local NHS Stop Smoking services in England offer medicines and expert support, and many also help with smokeless tobacco such as paan.

Wherever you live, your doctor can tell you what help exists near you. Help to stop is treatment, not a telling-off, and asking for it is a normal part of an appointment.

Tell your doctor about every form of tobacco you use, not only cigarettes. The Pakistan Menopause Society asks doctors to ask about smoking and tobacco use as part of a woman's long-term health picture, alongside heart risk, bone health and diabetes (Table 2). Naswar and shisha belong in that answer too.

Book an appointment if you want help to stop, if you are weighing up menopause treatment, or if you have questions about your heart or bone health.

Some women ask whether tobacco is permitted. That is a question for a qualified scholar, and this page does not answer it.

At home, tobacco is often private. A woman may hide naswar from her family, or feel she cannot refuse shisha at a gathering where everyone shares it. The Pakistan Menopause Society lists husband and family support, honest talk and seeking professional help without stigma as part of menopause care (4.2.6). If you want to stop, telling one person at home is one way to begin.