Water pipe for tobacco
In many parts of the world people use a waterpipe to smoke tobacco. This is particularly true in the Eastern Mediterranean Region, where waterpipes are known variously as shisha, goza, narghile, ghalyoon or hookah.
A waterpipe works by placing a tobacco product in a small bowl with holes in the bottom which is attached to a tube linked to a water container. When the tobacco product is heated by hot charcoal placed on the tobacco it emits smoke that the user inhales by puffing on a hose connected to the water container. This draws it through the water and into their lungs.
Health risks of waterpipe tobacco use
Waterpipe tobacco use is damaging to health in similar ways to cigarette tobacco use. However, the health dangers of waterpipe tobacco use are often little understood by users. For instance, it is often wrongly believed that the smoke is purified by passing through the water in a waterpipe. Waterpipe tobacco use is not a safe alternative to cigarettes, and there is no proof that any device or accessory can make waterpipe smoking safer.
Using a waterpipe to smoke tobacco may seriously damage the health of smokers and the health of those exposed to the second-hand smoke emitted. It is important to remember that:
Waterpipe tobacco has significantly higher nicotine content than cigarettes. One head of unflavoured tobacco has the nicotine equivalent of 70 cigarettes.
Waterpipe tobacco also contains numerous toxins known to cause lung disease, cancer, heart diseases and other illnesses. Even after it has been passed through water, the smoke produced by a waterpipe contains high levels of toxins, including carbon monoxide, metals and cancer-causing chemicals. A typical 1-hour long waterpipe smoking session involves inhaling 100–200 times the volume of smoke inhaled with a single cigarette.
The fuels used to heat waterpipes, including wood cinders and charcoal, produce toxins that contain high levels of carbon monoxide, metals and cancer-causing chemicals. Second-hand smoke from waterpipes is a mixture of tobacco smoke and smoke from the fuel, and therefore poses a serious risk for those inhaling it, especially children. Waterpipe use or exposure to second-hand smoke from a waterpipe can also have adverse effects during pregnancy.
Waterpipe use is linked to chronic bronchitis and respiratory disease. It also facilitates the transmission of hepatitis and herpes viruses, as well as being implicated in the transmission of an estimated 17% of cases of tuberculosis in the Region.
Increasing use of waterpipe tobacco
Waterpipe tobacco is highly addictive and its use in the Region is increasing rapidly, especially among young people and women. The Region has some of the highest rates in the world with overall rates of use of tobacco products other than cigarettes (including waterpipe tobacco) of 14% among boys age 13–15 (compared to 7% cigarette use) and 9% among girls age 13–15 (compared to 2% cigarette use). These rates are even higher in some countries of the Region. In many countries, more women and young people use other tobacco products than smoke cigarettes.
Underlying this increase is the misperception that use of tobacco products such as waterpipe tobacco is less harmful to health than smoking cigarettes. Waterpipe tobacco is not a safe alternative to cigarettes. However, the health dangers of waterpipe tobacco use are little understood by users.
Marketing waterpipe tobacco
Waterpipe smoking is becoming part of a new lifestyle trend in many countries, as a popular way to spend time with friends socializing. It is being promoted as fashionable and sophisticated. It is sometimes also portrayed as a traditional activity, appealing to people’s sense of identity and heritage. Waterpipe tobacco is available in sweetened flavours such as apple, strawberry, grape, cherry, mint and cappuccino that may particularly appeal to young people and women.
Waterpipe tobacco has not had the same amount of regulation as cigarettes. In most countries, the tobacco mixtures sold for waterpipe tobacco use do not carry health warnings on their packaging. This reinforces the perception that waterpipe tobacco use is relatively safe compared to smoking cigarettes. Some waterpipe tobacco mixtures state that they contain no tar, which is technically accurate but misleading because tar is produced during the combustion of the tobacco.
Best practices and the way forward
Waterpipe tobacco should be subjected to the same regulation as cigarettes and other tobacco products. This includes application of Article 9 of the WHO Framework Convention on Tobacco Control on the regulation of the contents and emissions of tobacco products, Article 10 on the regulation of tobacco product disclosures and Article 11 on packaging and labelling of tobacco products.
Waterpipe tobacco use should be included in tobacco control efforts. This includes:
prohibition of misleading labelling and claims of reduced harm and safety
having health warnings on waterpipe tobacco packaging
waterpipe tobacco use being prohibited in public places consistent with bans on cigarette use
education of the public and health professionals about the health risks of waterpipe tobacco use, including exposure to second-hand smoke
cessation interventions for waterpipe tobacco users.Waterpipe tobacco use is damaging to health in similar ways to cigarette tobacco use. Waterpipe tobacco is highly addictive and its use in the Region is increasing rapidly, especially among young people and women. Underlying this increase is the misperception that use of tobacco products such as waterpipe tobacco is less harmful to health than smoking cigarettes. Waterpipe tobacco should be subjected to the same regulation as cigarettes and other tobacco products.
Waterpipe, hookah, or shisha all disguise their harmful tobacco smoke in myths of water filters and sweet candy flavors. Waterpipe smoke is, in fact, deadly. Incorporating bans on waterpipes into smoke-free policies will help dispel these myths.
Ma’assel in Syria
Most water pipe smokers in Syria started smoking in the early 1990s, after the introduction of ma’assel.
In a 2002 survey of water pipe cafés in Aleppo, most water pipe smokers reported initiating smoking after 1990, a date marked by the introduction of ma’assel smoking tobacco.
The water pipe is a tobacco smoking device with roots in India, Africa, and the Middle East. Water pipes have been used for centuries, but the introduction of ma’assel in the early 1990s, a molasses-soaked smoking tobacco, triggered a surge in use outside the traditional water pipe user base of older males. Water pipes employ an indirect heat source (such as lit charcoal) to slowly burn tobacco leaves while users draw smoke down through a water chamber and into their mouths through hoses. Along with the sugary molasses, ma’assel is flavored heavily with apple, banana, orange, vanilla, and other fruit or candy tastes.
Water pipe smokers often falsely believe that this form of tobacco use is less harmful than smoking cigarettes, a notion which must be dispelled by thorough, aggressive educational efforts. When hot smoke passes through water at the base of the water pipe, the smoke cools, and is then easily and deeply inhaled by even first-time tobacco smokers. The heavily flavored and cooled water pipe smoke is inhaled in massive quantities. The water’s cooling effect may actually increase harm by enabling water pipe smokers to inhale smoke deeper into their lungs.
Ma’assel is the molasses-soaked smoking tobacco commonly burned in water pipes in the Middle East, Europe, and North America, was introduced to the world in the early 1990s.
Up to 77% of ma’assel packages indicate the percentage of ‘tar’ in the product as 0.0%. The tobacco industry deliberately misrepresents the harm posed by smoking water pipe tobacco.
Percentage of adults currently using water pipes in Middle Eastern countries
Water pipe use has been traditionally based in the Middle East and has high prevalence in many countries in the region.
Grant, Aimee, Rory Morrison, and Martin J. Dockrell. “Prevalence of Waterpipe (Shisha, Narghille, Hookah) Use Among Adults in Great Britain and Factors Associated With Waterpipe Use: Data From Cross-Sectional Online Surveys in 2012 and 2013.” Nicotine & Tobacco Research: 16, no. 7 (July 2014): 931–38. doi:10.1093/ntr/ntu015.
Baron-Epel, Orna. “Re: Nargila Smoking in Israel- Question,” October 5, 2014.
Khattab, Adel et al. “Smoking Habits in the Middle East and North Africa: Results of the BREATHE Study.” Respiratory Medicine 106 Suppl 2 (December 2012): S16–24. doi:10.1016/S0954-6111(12)70011-2.
Morton, J et al, and on behalf of the GATS Collaborative Group. “Cross-Country Comparison of Waterpipe Use: Nationally Representative Data from 13 Low and Middle-Income Countries from the Global Adult Tobacco Survey (GATS).” Tobacco Control, June 11, 2013. doi:10.1136/tobaccocontrol-2012-050841.
Al-Houqani, Mohammed, Raghib Ali, and Cother Hajat. “Tobacco Smoking Using Midwakh Is an Emerging Health Problem – Evidence from a Large Cross-Sectional Survey in the United Arab Emirates.” Edited by Noel Christopher Barengo. PLoS ONE 7, no. 6 (June 15, 2012): e39189. doi:10.1371/journal.pone.0039189.
Ward, K D et al. “The Tobacco Epidemic in Syria.” Tobacco Control 15, no. Suppl 1 (June 2006): i24–i29. doi:10.1136/tc.2005.014860.
Names for Water Pipes
English and Native Script and the countries where a name predominates
- Hookah – India, Pakistan, USA, United Kingdom
- Shisha – Armenia, Azerbaijan, Cyprus, Greece, Iraq, Italy, Lebanon, Jordan, Palestine, Syria, Turkey, Uzbekistan
- (N)arghile – Bulgaria, Bosnia and Herzegovina, Croatia, Israel, Macedonia, Serbia
- Qalyān – Iran
- Dieu cay – Viet Nam
- Hubbly-bubbly – Egypt, South Africa
Water pipe smoking has been associated with elevated risks of lung, lip, mouth, and esophageal cancers. As widespread water pipe use is a recent phenomenon, large-scale high-quality studies on the long-term health effects of water pipe are still forthcoming. However, health scientists confidently predict that water pipe smoking will cause large-scale sickness and death similar to other forms of inhaled combustible tobacco products such as cigarettes.
Water pipe use has spread beyond the Middle East and is becoming integrated into the global tobacco market. In 2012, Japan Tobacco International purchased Al Nakhla, then the world’s largest water pipe tobacco manufacturer. Other transnational tobacco companies have explored moving into the water pipe tobacco market. Otherwise-strong smoking bans in Europe and North America sometimes have specific exemptions allowing the smoking of water pipes in cafés, enabling public smoking in otherwise smoke-free areas. Water pipe use is also on the rise among adolescents and young adults on college campuses and beyond, even among people who explicitly refuse to smoke cigarettes. Researchers must quantify the harms to health of this method of tobacco use and determine the best methods to stem the rise of water pipe use around the globe.
Women and Water Pipe
Proportion of All Tobacco Users that used Water Pipe by Sex, 2011
Water pipe use is especially difficult to confront because it often happens in homes, away from where traditional social pressures and policy interventions like smoking bans can have an impact. Notably, women in Middle Eastern countries are often frowned upon for using cigarettes, as they are a form of tobacco typically consumed in public, and are more likely to pick up equally harmful water pipe use.Waterpipe Waterpipe, hookah, or shisha all disguise their harmful tobacco smoke in myths of water filters and sweet candy flavors. Waterpipe smoke is, in fact, deadly. Incorporating bans on ]]>