Elsevier

Addictive Behaviors

Volume 36, Issues 1–2, January–February 2011, Pages 1-5
Addictive Behaviors

The global epidemic of waterpipe smoking

https://doi.org/10.1016/j.addbeh.2010.08.030Get rights and content

Abstract

In the past decade waterpipe (WP) smoking (a.k.a. hookah, shisha, and narghile) has been steadily spreading among the youth around the world. The allure of this tobacco use method for the youth can stem from its pleasant smooth smoke, social ambience and the perception of reduced harm. The material in this review is based on detailed Medline search for articles appearing especially in the past two years that are of relevance to WP epidemiology, health and addictive effects, and WP-related tobacco control policies. It shows that WP smoking is continuing to spread among the youth worldwide, and perhaps represents the second global tobacco epidemic since the cigarette. Available evidence suggests that the prevalence of current (past month) WP smoking range from 6 to 34% among Middle Eastern adolescents, 5%–17% among American adolescents, and that WP use is increasing globally. Studies on the health effects of WP smoking are limited by methodological quality, as well as by the novelty of WP epidemic relative to the long latency of important smoking-related health outcomes. Still, research indicates substantial WP harmful effects similar to those of cigarettes, as well as to the potential of providing a bridge to cigarette smoking or relapse. Developing effective interventions to curb WP use among the youth requires a detailed understanding of how dependence develops in WP users, and how it is shaped by WP's unique features such as the following; the predominantly intermittent use with prolonged sessions, preparation time, accessibility, potent sensory cues, and convivial experience of group use. It also requires assessing effective policy options such as factual and visible health warnings on all its parts, as well as youth access and indoor smoking restrictions. WP smoking is currently showing all signs of a burgeoning global epidemic with serious implications for public health and tobacco control worldwide. Investment in research and policy initiatives to understand and curb WP use needs to become a public health priority.

Research Highlights

► Evidence suggests a continuing spread of waterpipe smoking among youth globally. ► Waterpipe use is associated with considerable harmful effects and is addictive. ► To develop interventions we need to understand dependence in waterpipe smokers. ► Waterpipe smoking continues to fly under the global public health policy radar. ► Policy initiatives should address the multi-component nature of the waterpipe.

Introduction

Only some decade ago, including questions about the waterpipe (WP; a.k.a. hookah, shisha, and narghile) in epidemiological studies of tobacco use among the youth would have seemed unwarranted, even in the Eastern Mediterranean (EM) region considered by many as the cradle of this tobacco use method. Not including such questions nowadays, no matter where the study is conducted, will likely be a serious flaw. This reflects the dramatic changes in youth's tobacco use patterns worldwide, with non-cigarette forms, led by the WP, are becoming increasingly popular (Warren et al., 2009). In the most common form of WP used nowadays, burned charcoal pieces are placed on top of a perforated aluminum foil separating it from the flavored tobacco mixture (a.k.a. Maassel), so when the smoker draws air through the hose's mouthpiece, charcoal-heated air becomes smoke as it passes the tobacco mixture and cools as it bubbles through the water before inhalation by the smoker (Fig. 1) (Cobb et al., 2010, Gatrad et al., 2007, Knishknowy and Amitai, 2005, Maziak, 2008, Maziak, Ward, Afifi Soweid, et al., 2004, Maziak et al., 2007, Warren et al., 2009). These features, especially the passage of smoke through water (erroneously referred to as “filtering”), underlie much of the widespread misperception about WP's “reduced” harm and addictiveness. Recent research suggests that WP smoking is addictive and is associated with considerable harm (Akl et al., 2010, Cobb et al., 2010, Gatrad et al., 2007, Knishknowy and Amitai, 2005, Maziak, 2008, Raad et al., 2010). Unfortunately, evidence-based prevention and treatment interventions still lag behind, as is the knowledge base that can guide the development of such interventions (Maziak et al., 2007). In this review I want to provide an update about the global WP epidemic and the evidence about its harmful public health potential as it pertains to the development of treatment and policy interventions to curb its spread.

Section snippets

Is WP use a global public health problem or is it a passing FAD?

In recent years WP use has been witnessing a surge in popularity, especially among the youth in the EM region. In combination, the introduction of manufactured Maassel, reduced-harm perception, flourishing café culture and mass media have perhaps created optimal conditions for the thriving global waterpipe epidemic. For example, results of the Global Youth Tobacco Survey (GYTS) involving data from 16 countries and the Gaza Strip in the EM suggest that current (past month) WP smoking range from

WP's harmful potential

High quality studies of the long-term health effects of WP smoking are still lacking. A recent systematic review of the evidence concerning the health effects of WP smoking shows that WP smoking more than doubles the risk of lung cancer, respiratory illness, and low birth weight. WP smoking however, was not significantly associated with bladder cancer, nasopharyngeal cancer, esophageal cancer, oral dysplasia, or infertility, but the wide confidence intervals do not rule out such associations (

Conclusions and policy recommendations

Taken together, the presented data not only indicate that WP smoking has become a public health threat, but that this is perhaps the first tobacco use method since the cigarette that is showing all signs of a burgeoning global epidemic. They also indicate that the WP is running its specific epidemiological course, and that its harmful and addictive profiles are likely to be shaped by its unique features and use patterns. Despite these alarming trends most national and international tobacco

Role of Funding Sources

Funding for this review is provided by a grant from the National Institute on Drug Abuse (R01 DA024876).

Contributors

Maziak W wrote the review.

Conflict of Interest

The author declares that he has no conflicts of interest related to this article.

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