Objective: To describe the self-reported voice handicap and type of voice disorders in waterpipe smokers presenting with hoarseness, and to compare these outcome measures with those of cigarette smokers and non-smokers.

Methods: The medical records of all patients who presented with hoarseness between June 2022 and June 2025 were reviewed. Patients with a history of waterpipe smoking were included. Two groups, cigarette smokers and non-smokers, frequency matched by age and gender, were also included. Two voice outcome measures were used: the Voice Handicap Index-10 and voice diagnosis, categorized as structural, neurologic, or functional.

Results: Fifty-one waterpipe smokers, 51 cigarette smokers, and 51 non-smokers were included. The most commonly reported symptoms were hoarseness, vocal fatigue, and loss of range, with no statistically significant difference in prevalence among the three subgroups. The mean VHI-10 score in waterpipe smokers was 8.27 ± 8.58 compared to 7.59 ± 8.11 in non-smokers and 8.35 ± 9.69 in cigarette smokers (p=0.911). Waterpipe smokers had the largest percentage of abnormal VHI-10 scores compared to cigarette smokers and non-smokers (33.3% vs. 29.4% vs. 27.5%, respectively), but the difference was not significant. Regression analysis accounting for age, gender, reflux, and allergy showed no association between type of smoking and abnormal VHI-10 scores (VHI ≥ 11).
The most common voice diagnosis in all subgroups was structural voice disorders, followed by functional disorders. Analysis of vocal fold pathologies showed a significant difference in the prevalence of Reinke’s edema, leukoplakia, and granuloma (p=0.039, p=0.043, p=0.026, respectively). The prevalence of Reinke’s edema and leukoplakia was highest in cigarette smokers compared to waterpipe smokers and non-smokers. The most common vocal fold pathology in waterpipe smokers was vocal fold polyp (19.4%), followed by Reinke’s edema and leukoplakia (13.9%). Waterpipe smokers were 2.6 times more likely to have Reinke’s edema (OR=2.6; 95% CI [0.49–14.4]) and 1.27 times more likely to have leukoplakia compared to non-smokers (OR=1.27; 95% CI [0.32–5.05]).

Conclusion: There was no significant difference in self-perceived voice handicap or type of voice disorder among waterpipe smokers, cigarette smokers, and non-smokers presenting with hoarseness. A larger study is warranted.