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Waterpipe

Waterpipe, hookah, or shisha all disguise their harmful tobacco smoke in myths of water filters and sweet candy flavors. Waterpipe smoke is, in fact, deadly. Incorporating bans on waterpipes into smoke-free policies will help dispel these myths.

The water pipe is a tobacco smoking device with roots in India, Africa, and the Middle East. Water pipes have been used for centuries, but the introduction of ma’assel in the early 1990s, a molasses-soaked smoking tobacco, triggered a surge in use outside the traditional water pipe user base of older males. Water pipes employ an indirect heat source (such as lit charcoal) to slowly burn tobacco leaves while users draw smoke down through a water chamber and into their mouths through hoses. Along with the sugary molasses, ma’assel is flavored heavily with apple, banana, orange, vanilla, and other fruit or candy tastes.

Water pipe smokers often falsely believe that this form of tobacco use is less harmful than smoking cigarettes, a notion which must be dispelled by thorough, aggressive educational efforts. When hot smoke passes through water at the base of the water pipe, the smoke cools, and is then easily and deeply inhaled by even first-time tobacco smokers. The heavily flavored and cooled water pipe smoke is inhaled in massive quantities. The water’s cooling effect may actually increase harm by enabling water pipe smokers to inhale smoke deeper into their lungs.


Ma'assel is the molasses-soaked smoking tobacco commonly burned in water pipes in the Middle East, Europe, and North America, was introduced to the world in the early 1990s.

Up to 77% of ma'assel packages indicate the percentage of 'tar' in the product as 0.0%. The tobacco industry deliberately misrepresents the harm posed by smoking water pipe tobacco.

Waterpipe Use

Percentage of adults currently using water pipes in Middle Eastern countries

Water pipe use has been traditionally based in the Middle East and has high prevalence in many countries in the region.

Water pipe smoking has been associated with elevated risks of lung, lip, mouth, and esophageal cancers. As widespread water pipe use is a recent phenomenon, large-scale high-quality studies on the long-term health effects of water pipe are still forthcoming. However, health scientists confidently predict that water pipe smoking will cause large-scale sickness and death similar to other forms of inhaled combustible tobacco products such as cigarettes.

Water pipe use has spread beyond the Middle East and is becoming integrated into the global tobacco market. In 2012, Japan Tobacco International purchased Al Nakhla, then the world’s largest water pipe tobacco manufacturer. Other transnational tobacco companies have explored moving into the water pipe tobacco market. Otherwise-strong smoking bans in Europe and North America sometimes have specific exemptions allowing the smoking of water pipes in cafés, enabling public smoking in otherwise smoke-free areas. Water pipe use is also on the rise among adolescents and young adults on college campuses and beyond, even among people who explicitly refuse to smoke cigarettes. Researchers must quantify the harms to health of this method of tobacco use and determine the best methods to stem the rise of water pipe use around the globe.

 


Women and Water Pipe

Proportion of All Tobacco Users that used Water Pipe by Sex, 2011

Water pipe use is especially difficult to confront because it often happens in homes, away from where traditional social pressures and policy interventions like smoking bans can have an impact. Notably, women in Middle Eastern countries are often frowned upon for using cigarettes, as they are a form of tobacco typically consumed in public, and are more likely to pick up equally harmful water pipe use.

A single puff from a water pipe (450mL) is nearly equal to the volume of smoke inhaled from an entire cigarette (500mL).


The promotion of water pipe use is rooted in wilful ongoing misinformation that hookah water can magically clean up tobacco smoke. Nothing could be further from the truth.

 “WATER… HAS ONLY A SMALL EFFECT ON THE REMOVAL OF TAR AND TOTAL NICOTINE.”

British American Tobacco Research & Development, 1967

 


Waterford cigarettes

In 1966, a new American Tobacco Company cigarette featured a crushable water capsule. The company made claims that they were using the “oldest idea in smoking” (water filtration from a hookah) to enhance the taste of their cigarette. This cigarette debuted as companies used words like “taste” to signal that one cigarette was “healthier” than another. The American Tobacco Company was willing to leverage the idea that hookahs filtered smoke effectively through water to sell a supposedly less harmful cigarette.

This development is historically notable because:

1. The industry was willing to utilize the idea of (supposed) harm reduction to sell cigarettes back in the 1960s.

2. This was the first “capsuled” cigarette, a technology that has resurfaced widely in recent years in the form of flavored capsules to sell cigarettes, especially to youth.


References

Aslam HM, Saleem S, German S, Qureshi WA. Harmful effects of shisha: literature review. Int Arch Med. 2014;7:16.

Maziak W, Ward KD, Eissenberg T. Interventions for waterpipe smoking cessation. Cochrane Database Syst Rev. 2007;(4):CD005549.

Maziak W. The global epidemic of waterpipe smoking. Addict Behav. 2011 Jan;36(1-2):1-5.

Maziak W, Nakkash R, Bahelah R, Husseini A, Fanous N, Eissenberg T. Tobacco in the Arab world: old and new epidemics amidst policy paralysis. Health Policy Plan. 2013 Aug 19;czt055.

CDC's Office on Smoking and Health. Hookahs: Smoking and Tobacco Use Fact Sheets [Internet]. Centers for Disease Control and Prevention; 2013 [cited 2014 Jun 27]. Available from: http://www.cdc.gov/tobacco/data_statistics/fact_sheets/tobacco_industry/hookahs/index.htm