Waterpipe smoking might be just as harmful as smoking cigarettes

Reem Waziry and Elie Akl

 Waterpipe, also known as shisha, goza, narghile, arghile and hookah, is a traditional method for smoking tobacco. While it originated in Turkey, India and Iran, its use has spread on a global level over the past decade to the point of being labelled a global epidemic.

There are a number of explanations for the global spread of waterpipe tobacco smoking. First, people use it as a way to socialize, as it is smoked in groups. Second, the production of sweetened and flavoured tobacco (Maassel), resulting in aromatic and smooth smoke, can make it more appealing than cigarette smoking. Another major reason is a common misconception that waterpipe tobacco smoking is not harmful, or is less harmful than smoking cigarettes.

In 2010 we conducted a systematic review of all published relevant studies on the impact of waterpipe tobacco smoking on health. The existing information at the time suggested that waterpipe smoking doubles the risk of lung cancer and respiratory illness, and of low birth weight. The current study represents an update of our 2010 review integrating relevant studies that have been published since then.

Since 2010, research in this field has grown in many settings worldwide. We found 24 new research papers that further associated waterpipe tobacco smoking with respiratory diseases, including chronic obstructive pulmonary diseases and bronchitis (and wheezes for passive waterpipe tobacco smokers). Waterpipe tobacco smoking was also associated with oral cancer, metabolic syndrome, cardiovascular diseases and poor mental health.

One study estimated that one cigarette can be smoked in 5 minutes yielding about 600 ml of smoke inhaled compared to a waterpipe smoking session that can last about an hour resulting in about 90,000 ml of smoke inhaled. However, none of the studies included in our review made a direct comparison between the effects of cigarette smoking and waterpipe tobacco smoking on health. In spite of this, it is becoming more certain that waterpipe tobacco smoking negatively affects human health in ways very similar to cigarette smoking.

What people worry about with waterpipe tobacco smoking is the ease with which young people can get hooked, addicted to nicotine, and eventually become cigarette smokers. Researchers in this field have labelled this phenomenon the gateway effect. Two studies that followed two cohorts of adolescents in Jordan and the United States respectively found that waterpipe smoking led to the initiation of cigarette smoking.

Collectively we can summarize the main message of our review as follows: Waterpipe tobacco smoking can lead to substantial harmful effects that are similar to those of cigarette smoking. Efforts are needed to design effective interventions aimed at correcting existing misconceptions, preventing people from taking up waterpipe smoking, and helping those who already smoke to quit. On a higher policy level, there is also a need for regulation and legislation to control the growing industry of waterpipe tobacco smoking.

Read more:

Waziry R, Jawad M, Ballout RA, Al Akel M, Akl EA. The effects of waterpipe tobacco smoking on health outcomes: an updated systematic review and meta-analysis. Int. J. Epidemiology 2016; doi: 10.1093/ije/dyw021 [free to access until 14 July 2016].

Image source: Flickr, CC BY ND.

About the authors:

Reem Waziry is a medical doctor trained in public health and currently a doctoral candidate at the Kirby institute, University of New South Wales Australia (Email: rwaziry@kirby.unsw.edu.au)

Elie Akl is a general internist interested in understanding and controlling the epidemic of waterpipe tobacco smoking. He is an expert in evidence synthesis and guideline development and is based at the American university in Beirut, Lebanon (Email: ea32@aub.edu.lb)

Follow co-author, Mohammed Jawad, on Twitter: @mojawad606