Shish' of a Time? The Health Implications of Waterpipe Smoking

“Every human being is the author of his own health or disease” Buddha

Smoking through a waterpipe, otherwise referred to as shisha, attracted attention in this weeks BBC health news: 'Shisha pipe smoking among young 'rising in Leicester'. The article expressed concern over the recent increase in Shisha users and once again challenged the misconception that Shisha smoking is safer than cigarettes. There is clearly a need for more to be done to get the health message across that smoking, in any form, is dangerous.

Over the past two decades tobacco smoking using waterpipes has become a massively popular and fashionable pastime among younger people. An activity normally shared with friends in homes, restaurants and cafes, shisha smoking has become socially accepted and widely regarded as a relaxing and an enjoyable experience. However, the rise in shisha smokers gives cause for concern because of the multiple associated health risks, of which people are either unaware or choose to ignore.  A report conducted in 2006 by the World Health Organisation (WHO) entitled, "Tobacco use in Shisha: Studies on waterpipe smoking in Egypt", claims that waterpipe smoking represents both a "modern renaissance of an old public health threat and the emergence of a new tobacco epidemic". 

Tobacco consumption has been linked to a high death rate worldwide (5 million deaths each year) and is considered to be the second major cause of death in the world that is completely preventable. With this statistic in mind, it raises the question; why do so many continue to smoke? 

The studies carried about by the WHO examining the effects of waterpipe smoking have all concluded that it is hazardous for our health. However, its growing popularity as a social, glamorous and harmless activity means much of the research has been overshadowed by people's misconceptions. Shisha smokers are thus left ill-informed and ignorant of the risks.

Dr Alan Shidaheh of the American University in Beirut says; "The historical lack of evidence has unfortunately allowed many Shisha users to believe that the practice was safe, or at least safer than other forms of tobacco use. We have recently learned otherwise.”

The History

The 2005 WHO Study Group on Tobacco Product Regulation "Waterpipe Tobacco Smoking: Health Effects, Research Needs and Recommended Actions" found that shisha has been smoked by people in Africa and Asia for at least four centuries. It is believed that a waterpipe was invented in India by a physician named Hakim Abul Fath who suggested that tobacco would be rendered less harmful if smoke was passed through a small receptacle of water. Thus, this widespread and unsubstantiated belief held by shisha users today - that the practice is safe - is as old as the waterpipe itself. 

Since the 1990s waterpipe smoking has become increasingly popular and is no longer dominated by older males in Middle Eastern countries.  Shisha smoking appears to have spread to new populations such as college students and young persons in the United States, UK and other European countries. 

Health Awareness - Battling the misconception

Although waterpipe smoking has not been studied as intensively as cigarette smoking, the preliminary research claims that it is associated with many of the same risks as cigarettes, and may in fact involve unique health risks.

The evidence affirms that the smoke that emerges from a waterpipe contains numerous toxicants which are responsible for causing oral cavity cancer, heart disease, tuberculosis and respiratory diseases. 

Waterpipe smoking, compared to cigarettes, is characterised by less frequent exposure (one to four sessions per day) but with a much more intense exposure per session, which can typically vary between 15 and 90 minutes. The uptake of tobacco nicotine is equivalent to 2-12 cigarettes per portion of tobacco used (hagar) and one person usually smokes several hagar per session. This translates into a nicotine intake equivalent to more than one pack of cigarettes per session. However, the waterpipe produces more smoke than cigarette smoking and thus overall smoke exposure could be as much as 100-200 cigarettes per session.

In addition, the temperature of burning tobacco in waterpipes is much lower than that in cigarettes, and the force needed to pull air through the high resistance of the water pathway, causes the smoke to be inhaled very deeply into the lungs. This is likely to cause patterns of cell injury in the oral and respiratory tracts. Smoking has also been shown to cause an accelerated decline in lung function.    

While it has been noted that the water does absorb some of the nicotine, waterpipe smokers can be exposed to a sufficient dose of this drug to cause addiction. Nicotine level intake in a standard session is similar to a single cigarette, yet the tar intake is 20 times greater. It is likely that the reduced concentration of nicotine in waterpipe smoke may result in smokers inhaling higher amounts of smoke and thus exposing themselves to higher levels of cancer-causing chemicals, alongside higher levels of arsenic, chromium and lead, as well as hazardous gases such as carbon monoxide.   

Professor Mostafa Mohamed, Professor of Community Medicine in Cairo and author of the 2006 WHO report stated that, “Heat sources that are commonly used in Shisha pipes to burn the tobacco are likely to increase the health risks because when they burn they produce their own toxins".

The report also points out that waterpipe smokers are exposed to a large number of genotoxicants via ingestion, respiration or absorption through the skin. Tobacco has been linked to mutations in the p53 tumour suppressor gene which leads to uncontrolled cell division and is found in over 50% of all human tumours.   

The study found that people who were waterpipe smokers were significantly more prone to develop hypertension and have higher blood pressure than non-smokers. The report also identified that waterpipe smokers are prone to repeated infections due to lowered immunity, and the habit of sharing waterpipes heightened the chance of contracting communicable diseases such as tuberculosis and hepatitis. There was ample evidence which showed that people who smoked were more likely to experience sleep disturbance. Thus the perception that smoking will help them relax and elevate their mood is, in fact, incorrect. 

The report highlighted that although further research needs to be done, there is strong viable evidence that exposure to waterpipe smoking is as harmful as the exposure to cigarette smoking, if not more so. 

Professor Mohamed affirmed that "Waterpipe smoking is growing epidemic. Any intervention programme to prevent this new threat must disabuse the public notion that waterpipes are less risky than cigarettes."  

What can we do?  

Changing our behaviour and habits is hard. Many people are reluctant to give up something they enjoy, particularly if its a social activity with friends. Hence it is easier to ignore the facts and live for the "now" rather than thinking about the consequences of our actions or wrongfully assuming that "it won't happen to me". 

We have to remember that our health is paramount and making sensible choices now can prevent unnecessary suffering later. 

Both the studies by the WHO point out that despite the strong evidence of health risks associated with waterpipe smoking, there remains few published studies on its negative effects. This has created an ambivalent and misguided picture of Shisha smoking.  More needs to be done to ensure people are educated about the dangers so that its reputation as a harmless and glamorous pastime gets demoted to unfashionable and unsafe!   

  

Education of health professionals, regulators and the public at large is urgently needed to make information more available. The WHO researchers stressed, “Waterpipes should be subjected to the same regulations as cigarettes and other tobacco products and should contain health warnings". 

RSPH  

The Royal Society for Public Health offer a course on Understanding Health Improvement Level 2 designed to provide knowledge and understanding of the benefits of good health and well being, and of the barriers to making a change of lifestyle.  For further information please contact Gina Mohajer.