The global epidemic of waterpipe smoking
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.
References (58)
- et al.
Is concern about waterpipe tobacco smoking warranted?
Australian and New Zealand Journal of Public Health
(2008) - et al.
Comparison of carcinogen, carbon monoxide, and ultrafine particle emissions from narghile waterpipe and cigarette smoking: Sidestream smoke measurements and assessment of second-hand smoke emission factors
Atmospheric Environment
(2010) - et al.
Waterpipe tobacco and cigarette smoking: Direct comparison of toxicant exposure
American Journal of Preventive Medicine
(2009) - et al.
Indoor air contamination during a waterpipe (narghile) smoking session
Food and Chemical Toxicology
(2009) - et al.
Beliefs and attitudes related to narghile (waterpipe) smoking among university students in Syria
Annals of Epidemiology
(2004) - et al.
Patterns of waterpipe use and dependence: Implications for intervention development
Pharmacology Biochemistry and Behavior
(2005) - et al.
Factors related to frequency of narghile (waterpipe) use: The first insights on tobacco dependence in narghile users
Drug and Alcohol Dependence
(2004) - et al.
Charcoal emissions as a source of CO and carcinogenic PAH in mainstream narghile waterpipe smoke
Food and Chemical Toxicology
(2008) - et al.
Waterpipe and cigarette smoking among college athletes in the United States
The Journal of Adolescent Health
(2010) Investigation of mainstream smoke aerosol of the argileh water pipe
Food and Chemical Toxicology
(2003)
Polycyclic aromatic hydrocarbons, carbon monoxide, “tar”, and nicotine in the mainstream smoke aerosol of the narghile water pipe
Food and Chemical Toxicology
Tobacco consumption among young adults in the two French departments of Savoie in 2008
Revue d'Épidémiologie et de Santé Publique
The effects of waterpipe tobacco smoking on health outcomes: A systematic review
International Journal of Epidemiology
Cigarettes & waterpipe smoking among medical students in Syria: A cross-sectional study
The International Journal of Tuberculosis and Lung Disease
Knowledge, attitude and perception of water pipe smoking (Shisha) among adolescents aged 14–19 years
Journal Of Pakistan Medical Association
Outcomes and adherence in Syria's first smoking cessation trial
American Journal of Health Behavior
Water pipe tobacco smoking among university students in Jordan
Nicotine & Tobacco Research
Water pipe tobacco smoking among middle and high school students
American Journal of Public Health
Clinical laboratory evaluation of potential reduced exposure products for smokers
Nicotine & Tobacco Research
Waterpipe tobacco smoking: An emerging health crisis in the United States
American Journal of Health Behavior
Exemptions for hookah bars in clean indoor air legislation: A public health concern
Public Health Nursing
Initial symptoms of nicotine dependence in adolescents
Tobacco Control
Hooked on hookah
Hookah smoking
British Medical Journal
A pleasure among friends: How narghile (waterpipe) smoking differs from cigarette smoking in Syria
Tobacco Control
Waterpipe smoking in students: Prevalence, risk factors, symptoms of addiction, and smoke intake. Evidence from one British university
BMC Public Health
Knowledge, attitudes and practice of university students regarding waterpipe smoking in Pakistan
The International Journal of Tuberculosis and Lung Disease
Cited by (292)
Particulate matter pollution in Hookah lounges in Palestine
2022, Journal of Aerosol ScienceWaterpipe tobacco smoke and health: What we have learned from rodent models?
2021, Life SciencesReprint of: Carbon monoxide poisoning in active or passive shisha smokers
2021, Journal Europeen des Urgences et de ReanimationThe Burden and Correlates of Waterpipe (Hookah) Smoking among Adolescents and Youth: A Systematic Review
2024, Substance Use and Misuse“It's nice to just be”: A qualitative study on the meaning-imbued reality of waterpipe smoking among young adults in Sweden
2023, NAD Nordic Studies on Alcohol and Drugs