Hookah Smoking from a Biomedical and Anthropological Perspective

We Cannot Say More than What We Knol about Shisha, Narghile, Hookah, “Water-pipe”...

Introduction

A hookah (shisha, narghile, goza, etc.) is not a ““waterpipe”” (in one word). This neologism proved to be a spurious scientific nominalism [1]. Most recent scientific evidence of its fatal consequences is exemplified by a recent cancer study in Egypt [2]). Unsurprisingly, a bibliometric ("scientometric") analysis found that this term was “over-represented” in the public health literature [3]. A hookah is a pipe that filters tobacco smoke (not only through water but as whole system) or, as it is more and more frequent these days, the one produced by heating a tobacco (or no-tobacco)-molasses and fruit based mixture in a bowl. The nature of the smoked products have changed to a certain extent: from raw plain tobacco (tumbâk, tumbeki, tütün) or jurâk (raw tobacco mixed with molasses [a sugar by-product] and/or soaked fruits, oils…) towards tobamel/moassel (mu‘assel in Arabic [i.e. a honeyed mixture]; “mel” meaning honey in Latin).
The question of which word to use is very important and the answer is very simple. Let us use, depending on the social and human context, the words peoples have been using for centuries. The three main ones are: hookah (from Arabic huqqa = vase/recipient, i.e. the base of the pipe); narghile (form Sanskrit and Persian for coconut, i.e. used as a water container)[note that nargile is the Turkish spelling]; and shisha (from Persian “shishe”= bottle/recipient).


Society and Culture

Through centuries, the corresponding practice has created a whole culture based on a peculiar form of sociability that young people in the English-speaking world sometimes term “social smoking”. Indeed, this conviviality (from Latin “convivialis”= related to sharing [a meal, etc.]) deeply stamped many societies of Africa and Asia. This “bel objet” [nice to look at artefact] is often seen as: a pretext for conversation; a socially, religiously and sexually egalitarian, playful, libertarian, situationist and poetic symbol of time passing; not to mention a “peace pipe" etc. [4].

Early medical anthropology research showed that children do not smoke the hookah and that women (particularly in Asia and Africa) are not accountable for the hookah epidemic, contrary to repeated statements by ""waterpipe"" experts [5]. As for the reasons behind the recent sudden world emergence of hookah smoking, up to 15 reasons were identified and published in key documents [6][7]. It is also noteworthy that the socio-cultural guard-rails (ritual, etiquette, etc.) were dissolved to a large extent as a result of the transplantation of the practice from its homelands to other continents (ibid.). 

    [picture: Traditional Palestinian woman with her narghile]


Origins

 
 The origins of the hookah go back far before the spread of tobacco across the world (16th –17th centuries). Contrary to international experts’ statements, the  hookah is not of Indian origin. Its history is very complex and the main lines of the latter were set out in a comprehensive publication [4]. This document identified an early archaeological work showing that the most ancient traces were found in Southern or Eastern Africa. For instance, bowls of water pipes were dug out in 1971 by J.C. Dombrowski in the Lalibela cave (Ethiopia). Carbone 14 datation established that their use go back to around 1320 +/- 80 A.D. [5][8]
. As one can see, this date precedes Christopher Columbus’ travel to America and the consequent tobacco habits brought to Europe a few years later and disseminated all over the world. Historical accounts show that the large scale emergence of hookah in society, either for an individual or collective use, occurrred simultaneously with that of public coffee-houses and the adoption of tobacco in the Middle East region : near the end of the 16th  century and the beginning of the 17th century [4]. 

  [picture: Persian qalyan. 17th century]


History of Research on Hookah Smoking

Research on hookah did not start off in 2002 as ""waterpipe"" experts recently and publicy stated [9]. There  had been numerous valuable scientific independent (this is very important) studies published over the last decades although, if a date were needed, it would be 1622 [6]. Because of their negative results, they have been systematically glossed over in present-day mainstream (antismoking) literature. Transdisciplinary (biomedical and social science) reviews of what research says about hookah smoking have been published over the last ten years and are still ongoing as exemplified by the first aetiologic study on hookah smoking and cancer ever published [1]. Focussing on the “water filter” is definitely a wrong approach to the problem. If it were so, then one should in fact consider six filters of varying efficiency, not only one: 1) the bowl where peculiar chemical reactions, very different from those induced by other tobacco use modes, occur ; 2) the vertical stem; 3) the water; 4) the suction hose; 5) the smoker’ lungs; 6) the socio-anthropological filter. Over the past centuries, the latter has definitively been the most powerful [1][10].


Thermodynamics, Physics and Chemistry of Hookah Smoking

The tobamel (moassel) is the most widely used product in Europe and the USA. It is actually a “light” and gooey version of the jurâk. It also contains glycerol which acts as a moistening agent and quite often flowers or fruits essences (apple, strawberry, rose, etc.). Once it is packed inside the bowl of the pipe, it must be covered with an aluminium foil pierced with small holes, that will be topped in its turn by one or several pieces of charcoal. The hot gases of their combustion, and not that of tobacco (as in cigarettes), will cause the “distillation” of some of its components (flavours, nicotine, etc.)  [6][11]. Today the use of opium or cannabis remains very limited.
Tar is a complex set of chemicals, some of them (nitrosamines, polycyclic aromatic hydrocarbons) being extremely toxic. Hookah smoking (including with tobacco-free tobamel) produces tar. However, it is very different from that produced by cigarettes because of the great differences in temperatures: hundreds of degrees, which, from a chemical viewpoint, is of utmost importance [1]. Notably, and in striking contrast with ordinary cigarettes, a great part of the aerosol in modern hookah is made up of dihydrogen monoxide [DHMO] and glycerol [12]. Undoubtedly, these last chemical compounds, and particularly DHMO [13][14] (video) are highly hazardous  for human beings and public health campaigns should emphasise this point.  Consequently, calculating and advertising cigarette-equivalents of hookah smoking sessions makes no sense, particularly when “smoking machines” are used for this purpose [5].

Carbon monoxide (CO) is mainly produced by the charcoal used to heat the smoking mixture. Its inhaled levels vary a lot and may reach those of pack-a-day cigarette smokers, particularly in ill-ventilated atmospheres [6][11][15]. CO is a very dangerous gas. Common symptoms of its action are headaches, pulse acceleration and muscular weakness. This is because CO prevents oxygen from binding to red blood cells and inside muscles [11].


Diseases

Hookah smoking has not posed any particular medical problem for centuries. However, it may today introduce new concerns because some of its inner anthropological characteristics, early documented but unfortunately censored, have been actually changing over the last 2 decades. For example, the nature of the smoked products changed or switched, as we said in the introduction: from raw plain tobacco of the tumbâk or jurâk types, both used within relatively standardised socio-cultural frameworks, towards tobamel/moassel. Amazingly, the latter produces a non-irritating smoke, much milder than that of a cigarette. This is, in part, because most of the irritants are watered down. As for the aldehydes (molecules that are quite aggressive to the respiratory mucous membranes), there is presently some confusion further to an experiment based on a biased  narghile smoking machine [16]. A critique of the latter was published [17]. Anyway, what is is noteworthy is that the users can inhale such a smoke directly into their lungs and, quite visibly, in great volumes.
When smoked on occasions, the health effects of hookah smoking could happen to be weaker or similar to those induced by the short “European” pipe or the cigar. Used heavily (one or more pipes a day), it may cause, in the long term, diseases comparable to those induced by cigarettes: particularly COPD (Chronic Obstructive Pulmonary Disease) [6][11]. Other potential, but not documented, risks include infarction and arteritis. As for communicable diseases, and further to the related errors contained in the WHO report and blindly cited in The Lancet, [18] a clarification has now been published [19].
As for cancer, a Pakistani-French team has found, thanks to two studies (one on mixed hookah/cigarette/bidi smokers and another one on exclusive/ever users), that overall CEA (CarcinoEmbryonic Antigen)[a biological marker for cancer] levels in the latter group were low compared to cigarette smokers. However, heavy hookah smoking substantially raises CEA levels [1].


Hookah and Addiction

For two decades now, the “Nicotine Addiction” model has been fatal for research in the field of cigarettes. Such a thesis is all the more irrelevant for the study of dependence in hookah smokers [1]. In Kuwait, a team has established with a rigorous methodology that the nicotine intake in hookah smokers is not as high as in cigarette users [20]. In Lebanon, researchers have 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 [21]. In this field, there is apparently no study on smokers of plain raw tobacco although early face-to-face interviews have been carried out and reported  in a transdisciplinary doctoral thesis. In fact, nicotine in hookah smokers depends on a multitude of factors and situations. Some people can draw each day the nicotine equivalent of a pack-a-day cigarette smoker and others, perhaps the majority, might not absorb that of a single cigarette   [1][10].  

  [picture: Dilating pharmacocinetics of nicotine in cigarettes smokers (right) and 3-day abstinent narghile dependent smokers (left)]. Source of the document: Chaouachi K. Cours sur le Narguilé. Université Paris XI 2007. 

The following statement to be found in the WHO report, and citing a study by the US-Syrian Centre for Tobacco Studies, is unsubstantiated: “Second-hand smoke from waterpipes […] poses a serious risk for non-smokers” [5][22].
Indeed, in striking contrast with cigarettes, hookah does generate almost no side-stream smoke [23] because of its peculiarities (charcoal topping the bowl and less elevated temperatures). So, the only smoke that should be taken into account is the one rejected by the smoker, i.e. the one filtered by the hookah at the level of the bowl, inside the water, along the hose and then by the smoker’s lungs themselves. 60 to 80% of the mainstream smoke particulate matter is retained in the lungs after inhalation” [24]. This last result, based on the review of  studies covering one century,  concerns cigarette smoke. It is even more relevant that hookah smoke is mainly made up of water and glycerol as in the Eclipse harm reduction cigarette. Consequently, the exhaled smoke is much less concentrated in most of the toxicants than that of cigarettes. It is expected to be far less toxic for non-smokers than cigarette side-stream smoke [1][10]. Sadly enough, the issue of hookah ETS hazards is highly biased and this is not good for the credibility of public health actions against the backdrop of a world epidemic. Some researchers even are In 2009, a 46 page study on this very issue was published in a peer-reviewed scientific journal. Its title is "Hookah (Shisha, Narghile) Smoking and Environmental Tobacco Smoke (ETS). A Critical Review of the Relevant Literature and the Public Health Consequences"(Open Access) [25] (table of contents available). A shorter version was made available in another peer-reviewed medical journal [26].
   
 [picture: WHO (World Health Organisation)-based photomontage (fake poster) by French INPES (Institut National pour la Prévention et l'Education à la Santé), officially used in 2006 campaign against narghile and its "environmental tobacco smoke"]
 

Breath is Life...

 
  • If you are a hookah smoker and you wish to go on smoking despite all what you knowsabout your practice, then avoid ill-ventilated venues and refrain from indulging in your habit more than one time a day...
  • If you wish to quit for ever hookah smoking, then avoid Nicotine “Replacement” Therapies (NRT) and associated products (patches, gums, etc.).  You will spare a lot of money because these "aids" are not efficient and very expensive. Choose a more adapted method; one that targets desire, not nicotine...
  • If you wish to quit hookah smoking but, for some reason, keep on on using tobacco, then think of harm reduction options like smokeless tobacco of the Swedish SNUS type [18].


Online Resources


Notes

  • This is a first draft. Please return for further hopefully updated and enriched versions.
  • Thanks to the team of The Sacred Narghile for its help in editing the English version of this text.  
 

Offer to Public Health National Authorities

 All plans against the world hookah epidemic have failed. Time has come for an evaluation of the corresponding strategies that led to this negative outcome. In the meantime, the author is ready to consider any mission for related intelligent policies and healthy prevention plans.

***********************************

References

  1. Sajid KM, Chaouachi K, Mahmood R. Hookah smoking and cancer. Carcinoembryonic Antigen (CEA) levels in exclusive/ever hookah smokers. Harm Reduction Journal 2008 (24 May);5(19)
    http://www.harmreductionjournal.com/content/5/1/19
  2. Chaouachi K. Micronuclei and Shisha/Goza Smoking in Egypt. Mutation Research/Genetic Toxicology and Environmental Mutagenesis 675 (2009) 81–82
    Hard Consequences of Using the ""Waterpipe"" Scientific Nominalism
  3. Millar N, Budgell BS. The language of public health—a corpus-based analysis. Journal of Public Health 2008;16: 369–74.
    http://www.lancs.ac.uk/postgrad/millarn/Files/Millar_Budgel_The%20language%20of%20public%20health.PDF
  4. Chaouachi K. Le Narguilé: Anthropologie d’un mode d’usage de drogues douces, Paris, L’Harmattan, 1997, 262 pages
  5. Chaouachi K. A Critique of the WHO’s TobReg “Advisory Note” entitled: “Waterpipe Tobacco Smoking: Health Effects, Research Needs and Recommended Actions by Regulators” (2005). Journal of Negative Results in Biomedicine 2006 (17 Nov); 5:17
    http://www.jnrbm.com/content/5/1/17
  6. Chaouachi K. Tout savoir sur le narguilé. Société, culture, histoire et santé. Paris [Eng.: Everything about Hookahs. Society, Culture, Origins and Health Aspects]. Maisonneuve et Larose 2007, 256 pages, colour.
    http://docs.google.com/View?docid=dgbz283m_19f97ts3
  7. Chaouachi K. Narghilé: un problema di Sanità Pubblica [Public Health and Prevention]. Tabaccologia 2006;4. 29-38
    http://www.tabaccologia.org/PDF/4_2006/7_42006.pdf
  8. Van Der Merwe NJ: Cannabis Smoking in 13th-14th Century Ethiopia: Chemical Evidence. In World Anthropology: Cannabis and Culture. Edited by Vera Rubin: Mouton Publ. (The Hague); 1975: 77-80
  9. Kozlowski, Kim. Michigan health leaders target growing hookah use. The Detroit News 2009 (14 Aug)
    http://detnews.com/article/20090814/LIFESTYLE03/908140351/1409/METRO/Mich.-health-leaders-target-growing-hookah-use
  10. [Comments on] Sajid KM, Chaouachi K, Mahmood R. Hookah smoking and cancer. Carcinoembryonic Antigen (CEA) levels in exclusive/ever hookah smokers. Harm Reduction Journal 2008 (24 May);5(19)
    http://www.harmreductionjournal.com/content/5/1/19/comments
  11. Chaouachi K. The Medical Consequences of Narghile (Hookah, Shisha) Use in the World. Revue d’Epidemiologie et de Sante Publique (Epidemiology and Public Health) 2007;55(3):165-70.[Article in English]
    Abstract
  12. Chaouachi K. Harm Reduction Techniques for Hookah (shisha, narghile, “water pipe”) Smoking of Tobacco Based Products. Med Hypotheses 2009 Oct;73(4):623-4.
    http://dx.doi.org/10.1016/j.mehy.2009.06.016
  13. Way, Tom. DiHydrogen Monoxide. DHMO Division 2009.
    http://www.dhmo.org/
  14. Video on the hazards of DiHydrogen Monoxide (DHMO)
    http://www.youtube.com/watch?v=yi3erdgVVTw
  15. Bacha ZA, Salameh P., Waked M. Saliva Cotinine and Exhaled Carbon Monoxide Levels in Natural Environment Waterpipe Smokers. Inhalation Toxicology 2007;19(9):771-7
  16. Al Rashidi M, Shihadeh A, Saliba NA. Volatile aldehydes in the mainstream smoke of the narghile waterpipe. Food Chem Toxicol. 2008 Nov;46(11):3546-9.
  17. Chaouachi K. Public health intervention for narghile (hookah, shisha) use requires a radical critique of the related “standardised” smoking machine. Journal of Public Health [Springer Berlin/Heidelberg] 2009; 17(5): 355-xxx. DOI : 10.1007/s10389-009-0272-7
    http://www.springerlink.com/content/58352477706011t0/
  18. Meleigy M. Waterpipe and communicable diseases link, says WHO. The Lancet/Infections 2007 (July); Vol 7; issue 7:448
    http://infection.thelancet.com
  19. Chaouachi K. Hookah (Narghile, Shisha) Smoking and Communicable Diseases. Tabaccologia 2008;1:47 [in English]
    http://www.tabaccologia.org/rivista.html
  20. Al-Mutairi SS, Shihab-Eldeen AA, Mojiminiyi OA, Anwar, AA. Comparative analysis of the effects of hubble-bubble (Sheesha) and cigarette smoking on respiratory and metabolic parameters in hubble-bubble and cigarette smokers. Respirology 2006; 11: 4...
  21. Salameh P, Waked M, Aoun Z. Waterpipe smoking: Construction and validation of the Lebanon Waterpipe Dependence Scale (LWDS-11). Nicotine Tob Res. 2008 Jan;10(1):149-58
  22. Maziak W, Ward KD, Afifi Soweid RA, Eissenberg T. Tobacco smoking using a waterpipe: a re-emerging strain in a global epidemic. Tobacco Control 2004; 13: 327-33
  23. Deckers SK, Farley J, Heath J. Tobacco and its trendy alternatives: implications for pediatric nurses. Crit Care Nurs Clin North Am 2006 (Mar);18(1):95-104
  24. Baker RR, Dixon M. The Retention of Tobacco Smoke Constituents in the Human Respiratory Tract. Inhalation Toxicology 2006; 17:255–94
  25. Chaouachi K. Hookah (Shisha, Narghile) Smoking and Environmental Tobacco Smoke (ETS). A Critical Review of the Relevant Literature and the Public Health Consequences. International Journal of Environmental Research and Public Health. 2009; 6(2):798-843.
    http://www.pubmedcentral.nih.gov/articlerender.fcgi?tool=pubmed&pubmedid=19440416
  26. Chaouachi K. Is Medical Concern about Hookah Environmental Tobacco Smoke Hazards Warranted ? The Open General & Internal Medicine Journal 2009; 3:31-3.
    http://www.bentham-open.org/pages/content.php?TOGMJ/2009/00000003/00000001/31TOGMJ.SGM
  27. Rodu B, Phillips CV. Switching to smokeless tobacco as a smoking cessation method: evidence from the 2000 National Health Interview Survey. Harm Reduct J. 2008 May 23;5:18
    http://www.harmreductionjournal.com/content/5/1/18

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Kamal Chaouachi
Kamal Chaouachi
Tobacco researcher and consultant. Lecturer at University Paris XI-XII (DIU Tabacologie)
Paris, France
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