Hookah Smoking as a New Public Health and Environmental Research Field

Hookah (narghile, shisha) smoking is an ancient mode of tobacco use which has not posed any particular public health problem over the past centuries [ 1 ] ( Figure 1 ).

Interestingly, its recent Middle East revival – and its transformation into a worldwide fashionable habit – coincided with the emergence of the ETS (Environmental Tobacco Smoke) – taken as synonymous to the SHS (Second Hand Smoke)-question in the early 1980s, particularly in North America and Western Europe. The reasons behind the growing popularity in the latter regions were early described elsewhere [ 2 ]. Fifteen motives, at least, could be identified. One of them assumes that the powerful anti-cigarette campaigns of the last decades would have, as a backlash effect, pushed a certain number of cigarette smokers towards a tobacco use mode viewed as less hazardous to health and, above all, less addictive. A recent study confirms the latter aspect, as it was found that more than 90% of so-called “mild smokers” (3 pipes or less per week) and about 50% of the so-called “moderate” ones (3 to 6 pipes per week) are considered as non dependent [ 3 ]. Existing scenarios for such a complex health and socio-cultural phenomenon, never witnessed before in the archives of tobacco research, have been proposed and revisited [ 4 ]. In these conditions, critical and comprehensive reviews of what sound scientific research says about hookah smoking health effects were necessary. The first one ever carried out can be found in a tobaccology (tobacco science) thesis dated 1998 and reworked later into a doctoral thesis [ 5 ]. This first review was updated several times and took the form, in particular, of a tetralogy on hookah and health [ 6 ]. Most recently, two teams from Asia and Africa have elicited a substantial advancement of research in this field. The first one analysed the potential health hazards associated with radioactivity in the smoking mixtures used in the narghile and found no great differences with cigarettes [ 7 ]. The other team led the first aetiological study on hookah smoking and cancer thanks to their fine selection of exclusive/ever hookah smokers who have been using, for decades, huge amounts of tobacco in their pipes. Using CEA as a cancer biomarker, they found a weaker association than that in cigarette smoking [ 8 ]. Such a study helped in clearing up a growing confusion caused, among others, by the dismissal of early biomedical and anthropological research on the subject [ 5 ].

Journal of the International Union of Tuberculosis and Lung Disease openly declares that hookah smoking might well be a ploy of the tobacco industry. Apart from various misquotations and errors, it also presents a selection of cancer studies with no comment on the fact that the participants were simultaneous or former smokers of cigarettes or other products [ British Medical Journal, regretting and lamenting the arrival of cigarettes in remote regions where only hookah had been traditionally used before. He said, after noting that “this form of smoking is less harmful than smoking cheap-brand cigarettes, as done by the majority of people in [his] country”: “I wonder how these representatives of the tobacco industry manage to reach the almost inaccessible hilly regions in the country”[ For instance, a recent review in theopenly declares that hookah smoking might well be a ploy of the tobacco industry. Apart from various misquotations and errors, it also presents a selection of cancer studies with no comment on the fact that the participants were simultaneous or former smokers of cigarettes or other products [ 9 ]. As for the purported link to the Tobacco Industry, a physician native of Nepal wrote, as early as 1962, to theregretting and lamenting the arrival of cigarettes in remote regions where only hookah had been traditionally used before. He said, after noting that “this form of smoking is less harmful than smoking cheap-brand cigarettes, as done by the majority of people in [his] country”: “I wonder how these representatives of the tobacco industry manage to reach the almost inaccessible hilly regions in the country”[ 10 ].

Another difficulty in this novel field of research that has received the attention and the funding of world organisations, has been frequent publications bias, not to mention linguistic bias or what some research labels “institutional provincialism” and other forms of ostracism [ 11 12 ]. Since a living hookah is not a mere “water pipe” laid on the table of a chemistry laboratory but generally involves a complex human and social situation, a short overview of recent findings about the health effects of hookah active smoking, i.e. exposure of the smoker to MSS, is necessary. Indeed, the first victim of “passive smoking” is the active smoker herself/himself [ 13 ].

et al. have compared the cytology of the BAL (bronchoalveolar lavage) fluid (macrophages, lymphocytes, neutrophils et eosinophils) and the lung function in 30 narghile users and 10 cigarette smokers. They found that regular use of narghile induces a rise in the overall cell number at the level of the BAL. However, it does not seem to bring about significant changes in lung function parameters when compared to cigarettes. The FEV1 (Forced Expired Volume in 1 second) and lung capacity were significantly higher [ Recently published studies from Asia and Africa are shedding new light on the potential diseases associated with hookah use through exposure to its MSS (active smoking). On the whole, exhaled CO by active smokers may be high in certain circumstances [ 1 14 ] and lung problems may arise in the case of heavy use. Metabolic effects could be similar to those observed in cigarette smokers [ 15 16 ]. As a general rule, studies on respiratory effects have been contradictory in the past. For instance, in Tunisia, Ourarihave compared the cytology of the BAL (bronchoalveolar lavage) fluid (macrophages, lymphocytes, neutrophils et eosinophils) and the lung function in 30 narghile users and 10 cigarette smokers. They found that regular use of narghile induces a rise in the overall cell number at the level of the BAL. However, it does not seem to bring about significant changes in lung function parameters when compared to cigarettes. The FEV1 (Forced Expired Volume in 1 second) and lung capacity were significantly higher [ 17 ]. However, a Syrian team has been able to shed new light on the respiratory effects of heavy narghile use among daily female users of tumbak (pure moistened tobacco, no molasses, no flavours, no glycerol). This was made possible thanks to their clear selection of exclusive/ever users. The researchers reported a higher proportion of chronic bronchitis in narghile smokers and quasi-permanent alteration of maximum Maximal Mid-Expiratory Flow (MMEF 25%–75%) in narghile smokers when compared with cigarette smokers. Nonetheless, FEV1 was more altered in cigarette smokers [ 18 ]. The risk of tuberculosis was highlighted and the lesser carcinogenic effect of narghile smoking brought out again [ 18 19 ]. This is in agreement, to a certain extent, with the recent aetiological study carried on in Pakistan [ 8 ]. As for communicable diseases, there has been some confusion now addressed in a recent review [ 20 ].

etc. Most of these terms refer to the water vessel in the corresponding languages. Three main smoking mixtures have been clearly identified: moassel, tumbak and jurak [ The hookah practice is striking by its great social, cultural, linguistic, material and geometrical diversity. For instance, the device bears such names as narghile (spelled “nargile” in Turkish), shisha, hookah, goza, madâ’a, qalyân,Most of these terms refer to the water vessel in the corresponding languages. Three main smoking mixtures have been clearly identified: moassel, tumbak and jurak [ 5 ]. One of the most important consequences of such a diversity is that the chemistry of smoke will be extremely different according to pipes, products and context. Reducing such a complexity through the use of an arbitrary name like “waterpipe” actually qualified for a scientific nominalism (see Glossary).

Furthermore, a widely endorsed functionalist bias occurred when complex social situations (those in which a hookah session takes place) were reduced to a laboratory model based on a “waterpipe” smoking machine supposed to replicate the emissions of toxicants actually inhaled by smokers during such social events. These methods have been criticised and, as an example, it was recalled that the FTC (Federal Trade Commission) and ISO norms suggest the use of a 1 minute machine smoking interval between 2 puffs in the case of cigarettes for which the duration of a laboratory session barely exceeds 5 minutes. However, and by a striking contrast, the “waterpipe” used in the laboratory was based on 171 steady puffs drawn every 17 seconds, i.e for one full hour, with the charcoal (heating source) on the same point over the smoking mixture. In these conditions, the nature and advertised yields of the measured toxicants in the smoke are highly questionable [ 4 21 ].

(Nicotine and Tobacco Research; American Journal of Health Behaviour) mistook one product for the other: tumbak for moassel or jurak. Also, by taking the above-mentioned smoking machine as a good approximation of the reality of hookah smoking, and ignoring the qualitative differences between hookah smoke and cigarette smoke, they went so far as to consider that, in “a standard waterpipe session”, a series of toxicant yields (nicotine, heavy metals, “tar”) are doses actually inhaled by smokers in the real world [ Another frequent confusion relates to the smoked products. As said before, these are of three main types – tumbak, moassel and jurâk – and they produce different chemical reactions in each case. However, the authors of recent studies in key journalsmistook one product for the other: tumbak for moassel or jurak. Also, by taking the above-mentioned smoking machine as a good approximation of the reality of hookah smoking, and ignoring the qualitative differences between hookah smoke and cigarette smoke, they went so far as to consider that, in “a standard waterpipe session”, a series of toxicant yields (nicotine, heavy metals, “tar”) are doses actually inhaled by smokers in the real world [ 22 23 ].

In fact, the smoke of hookah is chemically much less complex than that of cigarettes. This is due to the much lower temperatures to which the tobacco-molasses mixture is subjected: actually hundreds of degrees below that of cigarettes. Notably, and in striking contrast with ordinary cigarettes, a great part of the smoke is made up of water and glycerol when moassel is used [ 8 ]. It had been previously found that the water-soluble portion of cigarette smoke represented 38% of the particulate matter [ 24 ]. Interestingly, Middle East researchers have subsequently estimated the overall shisha water-filtration rate to be 38%, and concluded that shisha smoke, with only 142 compounds detected in a pipe filled with jurak (a mixture of 15% of tobacco leaves and 47% carbohydrates (glucose)), is actually far less complex than cigarette smoke [ 25 ]. This figure can be compared with the 4,700 substances identified so far in cigarette smoke [ 26 ].

For almost one decade now, public health organisations have failed to properly address the ever-growing world hookah epidemic despite their focus on hookah ETS hazards. A first example is a campaign poster designed by the French INPES (Institut National pour la Prevention et l’Education a la Santé) which was used during the 2005 “World No Tobacco Day” campaign sponsored by the WHO. The poster shows an important cloud of thick smoke stemming from a hookah and featuring the spectrum of death ( Figure 2 ).

Another example is a report by the American Lung Association whose cover shows, once again, a small-size hookah generating SSS on its own ( Figure 3 ). Unfortunately, what the tobacco experts who prepared both reports ignored is that, in contrast with cigarettes ( Figures 1 and 4 ), a hookah does not generate such a side-stream smoke.