Shisha: The Middle East’s favourite toxin

Imagine yourself smoking 150 cigarettes over the course of an hour. Think about the massive amount of poison you would inhale. Although it may sound like an exaggeration, that is what goes into the body during an average session of smoking shisha , Mitya Underwood reports

Health experts are starting to regard shisha, which is entrenched as a regional tradition, as a health epidemic more serious than cigarette. It has already become more popular than cigarettes among Emirati youth. Satish Kumar / The National
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The sweet, enticing smell that wafts from the doors of all shisha cafes is dangerously deceptive.

The waterpipe is not, as many still choose to believe, a pleasant pastime with health effects akin to smoking just a few cigarettes a day. It is hundreds of times worse.

Some of the latest research reveals that the inhaled smoke from a one-hour waterpipe session contains as much tar as up to 600 cigarettes, depending on the brand, and as much carbon monoxide as about 150 cigarettes.

Based on these figures, there is no question that shisha is dangerous to one’s health. So why are more and more young people taking up the habit?

“You can find a lot of people defending the waterpipe as ‘this is our way of living’ or ‘part of our culture’,” says Prof Wasim Maziak, the chairman of the department of epidemiology at Florida International University.

“Even if we accept that at face value, history shows that negative elements of culture need to be confronted and myths about them need to be dispelled, such as the myth about the benign nature of waterpipes compared to cigarettes.”

While the dangers of shisha have been discussed for some time, in the past five years experts have begun calling it an epidemic that needs urgent and affirmative attention.

This week, New York University Abu Dhabi is hosting a series of private lectures to establish more comprehensive waterpipe research to help shape future policy.

From today until Wednesday, researchers will gather to organise local and regional research collaborations to tackle unanswered questions about the habit. The findings from these will be presented at the 2015 World Conference on Tobacco and Health in Abu Dhabi. It will be the first time, in the UAE at least, that professionals of this calibre have gathered to focus solely on the waterpipe.

Prof Maziak, also a founding director of the Syrian Centre for Tobacco Studies, is one of the main participants and is giving a key lecture titled The Waterpipe: A Cultural Pastime or a Public Health Threat?

“The scholarly definition of an epidemic is a quick increase in the occurrence of something that is harmful to health,” he says, “and this is right on concerning the spread of waterpipe smoking. In fact, its global spread now to youth all over the world qualifies it as a global epidemic.”

In 2010 a group of researchers from the American University of Beirut, Lebanon, tried to quantify the level of risk associated with waterpipe smoke. Because of the difficulties surrounding the reliability of laboratory testing, they came up with an alternative method that involved directly measuring the smoke inhaled by a waterpipe user.

They measured inhaled nicotine, carbon monoxide and the tar from the waterpipe muassel (the flavoured tobacco).

Forty-three users were measured during one waterpipe session, lasting an average of 61 minutes. The results revealed for the first time the incredibly high quantities of the poisonous substances.

The average amount of smoke inhaled was 119 litres, which contained 150 milligrams of carbon monoxide, 4mg of nicotine and 602mg of muassel-derived tar.

The amounts of these substances in cigarettes vary depending on the brand and type. Some “ultra-light cigarettes” have just 1mg of tar and 0.1mg of nicotine. After smoking a waterpipe for an hour, the user will have inhaled the same amount of tar as if they had smoked 600 of these cigarettes. Other slightly stronger types have 6mg of tar, 0.5mg nicotine, and 7mg of carbon monoxide.

Even armed with this evidence, countries in the Middle East have done little to reduce their numbers of waterpipe smokers, and the number of new users is actually increasing.

A paper titled Tobacco in the Arab World: Old and New Epidemics Amidst Policy Paralysis, published in August and reseached by Prof Maziak, paints a rather gloomy picture.

“The bleak outlook of the tobacco epidemic in the Arab world continues to be faced with complacency in the form of underutilisation of surveillance systems to monitor the tobacco epidemic and prioritise action, and failure to implement and enforce effective policies to curb the tobacco epidemic,” it says.

Citing figures from the Global Youth Tobacco Survey, a World Health Organisation initiative, the report showed that waterpipe use among 13 to 15-year-olds in the UAE is far higher than the use of cigarettes.

Almost twice as many boys smoke shisha (about 20 per cent) than cigarettes, and four times as many girls (10 per cent).

“Among Arab youth in particular, numerous epidemiological surveys have documented the dramatic increase in waterpipe smoking, and it has now replaced cigarettes as the most common form of tobacco use in just a few years,” the report states.

Prof Maziak, who began researching tobacco control around 2000, said even at that time the waterpipe habit was “rapidly accelerating”.

“Before the 1990s waterpipe use was somehow confined to older men and was on the decline all over the region. However, in the early 1990s its use re-emerged somehow, and in a dramatic fashion. This time it wasn’t the older men, but young men and women who took up the waterpipe.”

Another of the problems associated with waterpipe smoking is the role it plays in encouraging people to take up cigarette smoking. Some experts reason that people will take up cigarettes because they are the most readily available source of nicotine.

Mohammed Taher runs a shisha cafe in Abu Dhabi that is visited by dozens of men every day. The 43-year-old started smoking shisha when he was just 13, and he also smokes about a packet of cigarettes a day.

“The fruity tobacco, the muassel, isn’t harmful at all,” he says. “The other sorts are worse. If young men go out with their friends to public places and smoke shisha, it is better than them being in a private place smoking drugs.”

One of his customers, Rami, an engineer who was born and raised in Abu Dhabi, admits he has two shisha sessions a day despite being an asthmatic.

The father of three estimates that an hour of shisha is probably the equivalent of smoking about one pack of cigarettes.

“I know it’s bad for me, but it’s a habit. I usually smoke it in my break from work and at home at night. Of course, I believe it’s addictive.”

The 36-year-old, who started smoking the waterpipe at 16, admits he smokes it in front of his two daughters, ages 9 and 6, and son, 2.

“They do see me, but I wouldn’t want them to smoke. I know it is bad, and it is of course addictive. Maybe 20 years back there were only five or six shisha cafes in Abu Dhabi. Now you are talking about hundreds.”

About a quarter of all deaths in the UAE are directly linked to smoking-related illnesses such as cardiovascular disease and cancer, according to government figures.

In 2015 Abu Dhabi will host the 16th World Conference on Tobacco or Health. The five-day event is expected to attract 3,000 specialists from around the world. The work beginning at NYU Abu Dhabi this week will form a basis for some of the discussions.

“Even with what we know now, we have enough evidence to start doing what we have done with cigarette smoking in terms of adopting public health policies that will limit smoking and protect non-smokers,” Prof Maziak says.

“The fact that we are doing the conference here in Abu Dhabi, and that major global health organisations such as the WHO have started ringing the bells about the harmful nature of this smoking method, shows that we are making good strides in putting this global emerging risk on the public health radar.”