Shisha, the social scourge In Egypt, the popularity of smoking shisha has become something of a phenomena; men, women and adolescents have taken up the habit oftentimes to "be part of the crowd and with the mistaken belief that it is healthier than cigarettes. The social pursuit of smoking shisha has undergone a huge resurgence over the past few decades particularly in the Eastern Mediterranean, South East Asia, and North Africa regions, according to the World Health Organisation (WHO). Even in the US and Europe, its popularity has soared with many cafes offering shisha (narghile, water pipe, hookah, hubble bubble are just a few of its pseudo names) and in some countries, shisha has defied public smoking (cigarette) bans. Smoking shisha however may not only be as dangerous as smoking cigarettes (according to the WHO), but has added health hazards due to the heat involved and the charcoal burning (releasing more cancer-causing substances and heavy metals) and sharing of the pipe (infectious agents such as tuberculosis, hepatitis A, Helicobacter pylori, pulmonary aspergillosis, may be spread by sharing the pipe). Although the tobacco content in each preparation of shisha is variable, one of three tobaccos are generally used; muessel, which contains about 30 percent tobacco, with the remainder of the contents usually being honey or molasses; tumbak or ajami, which contains a dark tobacco paste; and jurak, which may or may not contain fruits or oils along with tobacco. As the tobacco is burnt on the coals and passed through the water, where it is cooled before it is inhaled, many smokers mistakenly believe this process gets rid of the toxins and makes shisha safer than cigarettes. Evidence to the contrary has recently been published in a review in Pediatrics that found the nicotine content in shisha tobacco to be between 2 and 4 percent, compared to between 1 and 3 percent for cigarettes; and the carbon monoxide (CO) concentration in shisha to be 0.34 percent to 1.40 percent compared to 0.41 percent for cigarette smoke, with CO being more concentrated in the smaller-sized water pipes than those used for commercial use. CO levels are also more elevated in shisha smoke due to the burning of the tobacco on the charcoal. As well as containing significant amounts of nicotine, the mainstream smoke from shisha also contains high amounts of tar, heavy metals, arsenic, chromium and lead, especially when compared to smoke in cigarettes. Furthermore, compared to smoking cigarettes, the mode of smoking shisha (frequency of puffing, depth of inhalation and the length of the smoking session) exposes the shisha smoker to higher concentrations of smoke. Shisha smokers may smoke for several hours at a time and may breathe in more deeply because of the less irritating nature of the moisturised smoke, which is further camouflaged by the fruit flavors that are added to the tobacco. A review by researchers at Virginia Commonwealth University found that a session of hookah smoking which lasts approximately 45 minutes will deliver 36 times more tar, 15 times more carbon monoxide and 70 percent more nicotine than a single cigarette. Other studies have shown that shisha smokers have increased end-expiratory (end exhaled air) CO levels, carboxyhemoglobin concentrations (CO in the cigarette smoke binds to hemoglobin replacing oxygen resulting in carboxyhemoglobin), and levels of nicotine, cotinine (a major metabolite of nicotine), arsenic, chromium, and lead. Generally, a cigarette will last no more than 5 minutes, which makes approximately 9 cigarettes in order to compare to the 45 minutes hookah session. Confirming these results, the WHO has recently stated that a single session of smoking shisha yields a nicotine intake equivalent to more than one pack of cigarettes and that "a typical one hour smoking session with water pipe leads to inhaling 100-200 times the volume of smoke inhaled with a single cigarette . Of the few studies carried out on the medical effects of shisha, all suggest that these are similar to those associated with cigarette smoking, including; lung and other cancers, impaired lung function, coronary heart disease, tobacco dependence, infertility and low birth weight (in babies born to shisha smoking mothers). The added risk of contracting infectious diseases is a particular problem for countries such as Egypt where the increased use of shisha is thought to have increased the prevalence of tuberculosis and other infectious diseases. In addition, in Egypt, a third of all tobacco-related deaths, are from shisha smoking (according to the Egyptian Smoking Prevention Research Institute) a statistic that warrants more studies, awareness and caution on shisha use. WHO's recent statement that "there is no proof that any device or accessory can make water pipe smoking safer should surely deter many people from pretending otherwise, and perhaps stop serving shisha in their homes, as if it is the next best thing to sliced bread, or a pair of Gucci shoes. Dr May El Meleigy holds a Ph.D in Immunology from the London School of Hygiene and Tropical Medicine, as well as an MSc. (Toxicology/pathology) and a BSc in pharmacology) from London University. El Meleigy is a freelance medical/health writer and is currently producing Health Education programs for Egyptian TV.
