Cancer Rates on the Rise - says new report by WHO

The World Health Organisation’s (WHO’s) International Agency for Research on Cancer (IARC) has today published a new “World Cancer Report 2014” to coincide with World Cancer Day. The report highlights the growing rates of cancer around the world and advises that stronger efforts on prevention are needed to tackle this problem.

The IARC estimates that the global burden of cancer will rise from around 14 million new cases per year in 2012 to 22 million within the next 20 years

The report identifies that due to growing ageing populations, developing countries are disproportionally affected by growing rates of cancer. It is believed that over 60 percent of the global burden is in Africa, Asia and Central and South America, were 70 percent of cancer sufferers die. A lack of early detection and treatment are a particular concern.

The report argues that half of all cancers could be avoided, if measures to prevent the disease are put in place. 

There is now a wealth of information on cancer available as well as more effective and efficient ways to treat the disease. However, more is needed to ensure early detection and fair access to treatment.      

Dr. Christopher Wild, report co-editor and director of the IARC, says:

"Despite exciting advances, this Report shows that we cannot treat our way out of the cancer problem. More commitment to prevention and early detection is desperately needed in order to complement improved treatments and address the alarming rise in cancer burden globally."

Cancer continues to be the leading cause of death worldwide and therefore a huge global public health issue. Statistics reveal that in 2012 there were 8.2 million deaths to cancer, with lung cancer being the highest (1.59 million deaths), followed by liver (745,000 deaths), colorectal (bowel) (694,000 deaths) and breast (521,000) to name a few.

In addition, the costs associated with cancer can be very damaging to even the richest nations and very hard hitting for the poorer ones.

In 2010, the total global annual cost of cancer reached an estimated US$1.16 trillion

The report advocates that half of all cancers could be avoided, saving millions of lives a year, if detection is made early enough and if we implement the knowledge that we already know. This also includes individuals being aware of high risk behaviour and consequently taking steps to limit their chance of developing cancer.    

Currently, tobacco use has the single biggest impact, with 22 percent of global cancer deaths and over 70 percent of global lung cancer deaths

It is estimated that around 30 percent of cancer deaths could be prevented if certain health risk factors are avoided and or reduced. These namely include, stopping smoking, reducing alcohol consumption, preventing being overweight, eating healthily and increasing levels of physical activity.

For information on understanding the importance of health and how to help and support others to make healthier changes, visit http://www.rsph.org.uk/en/training-solutions/index.cfm to view a list of our training programmes.   

The World Heart Federation calls on all countries to set a target year to end tobacco use

At the Tobacco End Game Conference in New Delhi, India this week the World Heart Federation (WHF) signalled to all countries worldwide to set a target year to end tobacco use in their country. Ending tobacco use implies reducing population smoking levels to five percent or below.

Some countries have already taken the lead and have announced their “target year” to reduce tobacco consumption. These include Finland (2030), Scotland (2034), New Zealand (2025) as well as a few Pacific Island States (2025).  

The Risks

Previous Blogs, “Raising Awareness for Lung Cancer” and “Smoking – a big turn off”  have highlighted the negative impacts of smoking on health, and the evidence continues to affirm that tobacco use is one of the main risk factors for heart disease and is the cause of millions of premature deaths each year worldwide.

Smoking is estimated to cause nearly ten percent of cardiovascular disease (CVD) and is also the second leading cause of CVD after high blood pressure. Further more, it is not just smokers who bear the consequences of tobacco smoke, passive smokers are also placed under unnecessary risk.

Figures indicate that nearly six million people die from tobacco use or exposure to second hand smoke worldwide, every year. By 2030 is it believed that tobacco-related deaths will increase to over eight million deaths a year.

With strong evidence available to the public on the adverse effects of smoking and the efforts to promote these facts, the statistics on tobacco related deaths remain shocking!  

Thus, important questions arise about what else we need to be doing to reduce smoking in adults and prevent children from starting.

Could further changes in marketing be the answer?

Over the past decades the UK has witnessed some significant changes to how tobacco is advertised and this began in the early 1990’s but took greater affect after the millennium.  The 1990 and 1996 Broadcasting Acts prohibited tobacco marketing on broadcast media (television and radio). However, it was the Tobacco Advertising and Promotion Act 2002 (TAPA) that banned most forms of tobacco advertising. This included a ban on print media and billboard advertising (2003) and advertising at the point of sale (2004).

As the UK is a Party of the Framework Convention for Tobacco Control (FCTC) they were bound by agreement to implement the framework into national policy.  The drive to improve population health coupled with the requirement to integrate further restrictions on tobacco advertising, saw a new national tobacco control strategy emerge in 2008 by the Labour Government and later reinforced by the Coalition Government in 2011. The consultation included a ban on the display of tobacco in shops and a ban on tobacco vending machines (2011) both of which were included in the Health Bill.

Since April 2012 it has become illegal to display tobacco products at the point of sale in large stores and this ban will come into force in smaller stores from 2015. Although in 2010 the Coalition government agreed to review the evidence for plain packaging as part of its national strategy, this has still not come into affect, despite pressing evidence that branding of tobacco packets and higher consumption rates exists. Read the RSPH press release here on our disappointment of not introducing standardised packaging on tobacco products.

“Research shows that Point of Sale (PoS) display has a direct impact on young people’s smoking. In 2006, almost half (46%) of UK teenagers were aware of tobacco display at PoS and those professing an intention to smoke were more likely to recall brands that they had seen at the point of sale.”

Tobacco companies invest large amounts of resources in branding their products and making them appear as attractive as possible. They know that brand imagery is much more important to younger age groups, thus standardised packaging would reduce brand appeal and reduce the inclination to smoke.

Next Steps

Clearly, measures have been made to reduce smoking in the UK, tighter restrictions on tobacco advertisement and the implementation of the smoking ban in public spaces 2007/2008 have sought to reduce appeal for smoking. However, there remains more to be done to ensure we are able to align ourselves with the World Heart Federations’ aim to reduce tobacco use below 5% and prevent thousands of avoidable deaths a year (in England the current ambition is to reduce smoking prevalence to 18.5% or less by 2015; to 12% or less among 15 year olds by 2015). 

The World Heart Federation President Professor K Srinath Reddy said: "There is no hiding from the deadly effects of tobacco on heart health....There are many countries across all incomes making great strides in tobacco control and it should be possible for each of these nations to further bolster their tobacco control efforts by setting themselves a target year for reducing tobacco use below 5%. So the World Heart Federation would hope to see these countries, followed by those around the world, following the brave lead set by the countries that have announced target dates."

Visit RSPH Training Solutions to see programmes and courses that can give you the confidence and skills to help people make key lifestyle choices to improve their health.

For further information on UK regulations click here to read the ASH Briefing: UK Tobacco Control Policy and Expenditure.

For more information on the negative effects of tobacco use and how to quit please click here and NHS Choices website. 

The Seven Golden Rules for a Healthy Life

If we follow these simple steps, can we really reduce our risk of heart disease?

Cardiovascular disease (CVD) still remains the biggest killer in the UK.  In 2010, around 180,000 people died from CVD and 80,000 of these deaths were from coronary heart disease (CHD).  Although over the past decade, there has been a decline in death rates from heart disease in England, there still remains regional and socioeconomic differences in both incidence and case fatality, along with behaviour inequalities.

In 2010, the American Heart Association (AHA) proposed seven factors to help people understand the most effective ways of avoiding CVD and lowering the risk of developing cancer. 

The findings came from a long term study carried out by researchers from Northwestern University (Chicago), the University of Minnesota, and a number of other US research institutions; their findings were published in the peer-reviewed journal Circulation.  The cohort study followed 13,253 white and African American participants for between 17 and 19 years, to establish if maintaining ideal levels of the seven health factors could reduce heart disease and lower the risk of cancer. 

The Seven Simple Steps

• 1      Not smoking (never smoking or quitting more than 12 months ago
• 2      Maintaining a healthy body weight (that is a healthy Body Max Index (BMI)
• 3      Eating Healthily (diets rich in nutrition, fruits and vegetables)
• 4      Physical Activity (at least 75 minutes per week of vigorous physical activity, or 150 minutes per week of moderate or moderate plus vigorous activity
• 5      Having low cholesterol levels
• 6      Healthy blood sugar rates
• 7      Healthy blood pressure

The Findings

From the study, researchers found that the health benefits were higher among people who met the ideal levels for each of the seven factors.  For example, people who achieved ideal levels for six of more factors had a 51% reduced cancer risk and those who met the ideal levels of four factors had a 33% reduced rate of developing cancer.

While the findings have been welcomed, it is worth noting that smoking appeared responsible for the majority of the associations seen between the seven factors and cancer risk. This once again exemplifies how smoking has a direct correlation with your heart, blood pressure, circulation and individual risk of lung cancer.

What more can be done?

As highlighted above, CVD and CHD continues to be a major health concern in the UK, with health issues being more prevalent among low income earners. Those from lower socioeconomic groups are more likely to have poorer diets, lead sedentary lifestyles, suffer from mental health issues and partake in health risk behaviour, including smoking and alcohol abuse. These factors have a major impact on heart disease.

Type 2 diabetes and obesity are also some of the main contributors leading to CVD.  In England alone, a quarter of adults are obese and the prevalence of diabetes in the UK is around 5% for women and 6% for men.  The financial cost to society can also be detrimental.  The statistics reveal that in 2009, CVD cost the UK economy £19 billion – putting further strain on the health care system.

Although the AHA’s seven steps to improving health helps people to understand where to make the changes in their life (healthy eating, exercising), the problem is how to make these changes?  For most people, breaking old habits and changing behaviour can seem like an impossible task, and for some, change is not always welcomed. How do we engage with people and offer advice on sensitive issues that could potentially save their lives?

The RSPH, having recognised the fundamental importance of behaviour change to improve health, has developed a qualification in Understanding Behaviour Change, Level 2 Award, to provide an understanding of communication styles and practical skills to help individuals implement lifestyle changes. The one day programme will also aim to give learners knowledge and confidence to offer brief advice and engage in brief interventions.  Sometimes, having the right conversation with someone can have far reaching positive affects.   For further information on the qualification please click here or contact Gina Mohajer.

For further information on heart disease visit the British Heart Foundation here

Understanding Behaviour Change: 

Happening at all levels

On the 29^th November 2012, the Royal Society for Public Health (RSPH) held a seminar on behaviour change. Led by Graham Rushbrook Development Advisor for RSPH, there was a chance to learn about the RSPH’s new Understanding Behaviour Change qualification, as well as to hear Kent Community NHS Health Trust’s experience of using the qualification. Participants then engaged in discussion about their experiences of obstacles to behaviour change for their clients.

The RSPH Understanding Behaviour Change qualification focuses on how best to support individuals in adopting positive behaviour change. At the heart of effective behaviour change is effective communication and relationship building. Within a one-to-one setting, the needs of the client are at the centre of all interactions, and the focus is on the holistic support of clients – not limiting support to narrow health requirements. As Graham highlighted, behaviour change “is done with, not to people”.

If individuals are to choose to change their lifestyles, any fear or ambivalence first needs to be addressed. It is also essential that an individual’s right not to change their behaviour is respected, and that the context and circumstances that may affect development of a plan to change lifestyle or health behaviour information is understood. The qualification also covers the importance of presenting information appropriately and accurately based on the needs of the individual, and teaches how to develop an effective lifestyle or behaviour change implementation plan and how to evaluate the impact of advice given.

Anne Ford, Head of Self Management and Prevention at Kent Community NHS Health Trust, spoke about her experience of using the RSPH’s behaviour change qualification to enable Health Trainers to support people with chronic health conditions. She highlighted that the effectiveness of behaviour change techniques lies in their client-centred nature and underlined the potentially valuable role of Health Trainers in supporting individuals in self management. The assessment of the Kent Community NHS Health Trust self-management and prevention plan has shown that through behaviour change training, Health Trainers have offered a wide range of support to clients, including referrals, signposting, accessing services from Age UK, organising respite care and supporting improvements in eating habits.

The RSPH qualification is set at Level 2, involves 16 hours guided learning time and is assessed through a multiple choice exam. Graham Rushbrook then led participants through a workshop session, asking participants to assess how the organisations, systems, disciplines and professions that they represent make it harder for clients to change.

Participants suggested that if behaviour change interventions are to be successful and sustainable:

-      There needs to be a holistic focus on the client, enabling underlying issues as well as health behaviours to be addressed. The client needs to be at the centre of the decision making process and interventions must be tailored to their needs.

-         Frontline staff need to buy into behaviour change techniques and training needs to be provided to enable them to work effectively with clear and consistent models. Communication between frontline services is vital if clients are to be treated holistically and effectively.

-    Behaviour change interventions need to be better understood by funders and management. This will involve recognition of the timescales involved (behaviour change interventions are not quick-fix) and also that quantifying results may not be possible in traditional ways.

Participants then looked at how these difficulties could be turned into opportunities for improving health. The focus in behaviour change theory on joined up services and holistic interventions, as well as developing partnerships was deemed an opportunity. In addition, moving the focus from assessing interventions based on quantity to assessment based on quality was seen as a huge opportunity for health improvement. It was also noted that behaviour change training can be achieved with little funding where training is offered in-house and that by sharing best practice between organisations and services, there is a great opportunity to ensure that behaviour change interventions meet their potential.

Next Steps

RSPH Training Solutions, will be running training sessions throughout 2013 to build understanding about behaviour change and to also build capacity to deliver the Behaviour Change qualification and training.  Our first date for this will be on the 26th February followed by a Train the Trainer programme on the 5th March.  For further information on opportunities to share best practice and offer in house training please contact Gina Mohajer, 0207 265 7327 or visit Training Solutions homepage. 

We will also be hosting further seminars around behaviour change to facilitate an engaged discussion with funders and commissioners about the case for supporting this type of intervention.  The next one will be in March, to register your interest, please contact Gina. 

RSPH In Conversation With… Professor Susan Michie

The Royal Society for Public Health (http://www.rsph.org.uk), with support from the Philipp Family Foundation, continues its series of podcasts, investigating key issues facing Public Health, with an international perspective.

In our interview with Professor Susan Michie, the topic is Behaviour Change, and how ”Western” lifestyles are storing up long term problems for the general population. With illustrations from the UK and around the world, Professor Michie discusses the huge economic cost of ill health, and the circumstances required to support people in making change to their lifestyles.

As the cost of health care continues to rise, and the UK Health Service is required to make substantial savings, this topic is of crucial importance. The majority of causes of ill-health are linked to people’s behaviour, whether through their lifestyle choices, their take up of vaccination and screening programmes or the way in which health care is delivered, so it is vital to learn lessons from other countries and from previous behaviour change campaigns.

You can listen to the interview with Professor Susan Michie, and previous podcasts with Professor Richard Parish and Professor Sir Michael Marmot now on the About Us page of the RSPH website or by clicking here. 

Why making just two lifestyle changes can have positive and far reaching affects on health

A recent study, at the Northwestern University Feinberg School of Medicine, found that changing one bad habit can have a positive knock on effect on other behaviours.  A simple step such as watching less television, can simultaneously reduce the amount of time one spends snacking on unhealthy foods – as these two behaviours are closely related.   As such, the notion that you must radically transform your life in order to be healthier is not necessarily true and often hard to maintain.  Making just a couple of small changes, as the study demonstrates, can have a real and long lasting impact on people’s health.

The study was conducted by Bonnie Spring, professor of preventive medicine at Northwestern University Feinberg School of Medicine, in an attempt to find out the most effective way to spur people to change common bad health habits.  204 adult patients with unhealthy habits, were given the following treatments; an increase in vegetables/fruit and physical activity and decrease in fat and sedentary leisure.  Over the course of the three weeks, the patients had to record their daily data into a personal digital assistant in order to establish if they met their goals. 

After the three weeks, patients no longer had to maintain their “healthier” lifestyles, but were still required to send data three days a month for six months.

After the completion of the six months, the study found that the patients kept to their new healthier lifestyle changes rather than reverting back to their old habits.  Around 86% of the participants said that once they had made the initial change, they tried to maintain it.  By incorporating fruits and vegetables in their diet empowered them to believe that they were in fact capable of change. 

The results indicated that the most effective way to improve health required two key behaviour changes, namely cutting the amount of time spent watching TV or on the computer and eating more fruits and vegetables.  It is believed that these two simple changes could have long lasting results.   

Spring said, "Just making two lifestyle changes has a big overall effect and people don't get overwhelmed."

The majority of the population, where obesity is most prevalent, often lead unhealthy and sedentary lifestyles, putting them at high risk for heart disease, diabetes and cancer.  Spring argues that it is often hard for doctors to know where to initiate change in unhealthy habits, without discouraging or offending patients.   Thus this “two way” simple approach enables others to make realistic and manageable changes by giving them confidence to carry it out.

“With this simplified strategy, people are capable of making big lifestyle changes in a short period of time and maintaining them”  


Photo by Sina Bahrami http://5127.co.uk/

Saving Lives Through Changing Behaviour

Fresh food, more exercise and no smoking.  These are some of the choices we need to make in order to lead a healthy lifestyle, which is sustainable in the long term.

The Royal Society for Public Health (RSPH) http://www.rsph.org.uk/ has responded to the Government’s White Paper, by developing a suite of training programmes on Behaviour Change designed specifically to support health and well being professionals to deliver these messages effectively as part of their behaviour change strategy. 

Professor Richard Parish, Chief Executive of RSPH comments:

“It is our belief that spreading skills and knowledge in this area will have a direct effect on driving behaviour change and reducing health inequalities, resulting in healthier communities across the country.”

Rises in obesity, diabetes, heart disease and sexually transmitted infections (STIs), alongside problems associated with unhealthy eating, drinking and smoking habits, have placed our health service under huge pressure.  As many health conditions are both preventable and avoidable, we have a responsibility to ensure that we intervene and steer people towards healthier lifestyle choices.  This not only positively impacts the wellbeing of the individual but also their communities.

Preventing avoidable conditions is better for both the patient and the health service, but the approach differs depending on the time available, the skill of the individual and the nature of the contact.

The programmes are tailored to help everyone and range from a short introduction for frontline staff right through to strategic planning for leaders and managers.

Influencing Behaviour Change

An introduction to communication and sign-posting

This one day workshop for front-line staff explores the potential improvements they could make to community health by influencing changes to behaviour. Drawing on motivational interviewing techniques and a variety of communication styles, participants will gain a clear understanding of how they can increase the impact of everyday contact with their community.

Making Every Contact Count

An introduction to the Behaviour Change competence framework

This half day programme introduces participants to the competence framework which has been developed by NHS Yorkshire and The Humber. It is designed for use at all levels of experience and provides a common approach against which skills can be assessed, either within a single programme or for an entire workforce. This will enable individuals to identify gaps in their knowledge, Commissioners to address weaknesses in their provision, and Service Providers to offer exactly what is needed.

To find out more about RSPH’s programmes on Behaviour Change please contact Gina Mohajer on gmohajer@rsph.org.uk 020 7265 7327or visit http://www.rsph.org.uk/en/training-solutions/index.cfm

Making Every Contact Count: An introduction to the behaviour change competence framework

So many aspects of healthcare are concerned with preventable or avoidable conditions. But the cost of dealing with them is under pressure more than ever before. A key theme in the Government’s next White Paper will be the need to reduce these costs, and every healthcare worker has their part to play. Every contact with a patient is an opportunity to encourage healthier lifestyle choices. But tackling sensitive issues such as weight loss, smoking cessation or alcohol abuse requires expertise, confidence and knowledge, in order to deliver the message effectively. Preventing avoidable conditions and encouraging behaviour change is an essential part of delivering an affordable health service for the future. Prevention is both better for the patient and cheaper for the provider. But do you and your team have the knowledge and skills to take this on? 

Prevention and Behaviour Change: a competence framework
The RSPH is offering a new programme designed to introduce participants to this competence framework which has been developed by NHS Yorkshire and The Humber.  It is designed for use at all levels of experience and provides a common approach against which skills can be assessed, either within a single programme or for an entire workforce. This will enable individuals to identify gaps in their knowledge, Commissioners to address weaknesses in their provision, and Service Providers to offer exactly what is needed.

This is a one day introductory programme, designed for those with an interest in encouraging behaviour change in their community or workforce. It is intended for people who will be playing a part in the development of healthy communities, whether as a Commissioner, provider of service or a member of frontline staff.  For further information or to book onto the course please contact Nicolette Boustaoui or by phone 020 7256 7325.

RSPH Training Solutions has also developed a unique suite of programmes called “Enabling and Guiding Choice for Health and Wellbeing”.  These include Influencing Behaviour Change and Behaviour Change in Practice.  In addition we will be running master classes and workshops for senior managers.  These suites will be available from September.  To register your interest or for more information please contact Nicolette Boustaoui or by phone 020 7256 7325.

Sport for Health: Bringing sport into people’s lives

The Royal Society for Public Health and the Mayor’s Sports Legacy Fund have launched a new two day course for sports leaders who would like to extend their experience and improve the health of their community.  The courses have been designed specifically for people who work or volunteer in sport.  

Sport for Health equips people with the skills to increase the level of physical activity of those who do not normally take part in sport and physical activity.

Participants will learn how an active lifestyle promotes good health and why behaviour change is so difficult for some people. They will also gain the practical skills to help people overcome these barriers and take part in physical activity.

Londoners may be eligible for up to 75% off the cost of the training in exchange for volunteer hours thanks to the Mayor’s Sports Legacy Fund, which is managed by the National Skills Academy for Sport and Active Leisure. This £3 million fund provides subsidised training to increase the number of Londoners working and volunteering in the sports sector, and up-skill those already involved, leading up to the 2012 Games.

Professor Richard Parish, Chief Executive of RSPH, comments “Sports leaders will gain a clear understanding of the key factors affecting health and well being, and the ability to communicate the benefits of sport and physical activity to others. They will have a better understanding of why many people are unwilling to get involved, and come away with practical ways to encourage a change in behaviour.”

National Skills Academy for Sport and Active Leisure CEO Florence Orban says: “A key goal of the Mayor’s Sports Legacy Fund is to remove barriers and engage Londoners who haven’t traditionally been involved in sport and active leisure, and the Sport for Health course clearly delivers on this. We are pleased to support this programme and encourage all eligible Londoners to apply for funding and help create a sporting legacy for 2012.”

The full price for each one day course is just £200 per participant and includes lunch, refreshments and full course materials.  The Mayor’s Sports Legacy fund will consider applications from people who commit to volunteering their skills with London communities.

To find out more about this course, available funding and other programmes offered by RSPH, please click here, call Nicolette Boustaoui on 020 3177 1625 or email sportforhealth@rsph.org.uk.   

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.