Shisha/Hookah
Shisha is a tobacco-based product that is smoked through a water bowl, sometimes mixed with fruit or molasses sugar, through a bowl and hose or tube.
Position Statement
Smoking is an addiction of childhood, so it is vital that shisha is addressed as part of an overall strategy to prevent youth uptake. An extension of the ban on flavoured tobacco products to include products designed for use in waterpipes, might begin to address the very real health problems presented by the growth of shisha usage.
Summary
Shisha itself is a tobacco-based product that is smoked through a water bowl. The tobacco is normally fruit flavoured which masks the harsh taste. The shisha usually contains a mixture of nicotine, light leaf tobacco, sugar by-products, carbohydrate by-products and sweet tasting flavourings which produce an aromatic smell. Some shisha products claim to be herbal or non-tobacco based. The actual instrument that is used to smoke the shisha is called a hookah, which translates as water pipe1.
Smoking shisha has its origins in India and the Middle East. Originally shisha use was seen as a social activity among the higher classes2. Although users of shisha are predominately from East Asian backgrounds, shisha use is rapidly becoming popular in the West and in particular with university students, with a prevalence rate of 7-11% in British universities3. Between 2007 and 2012 there was a 210% increase in the number of shisha cafés opening in Britain4.
Health issues and misconceptions
There are a number of health issues regarding shisha use, including the following:
A common misconception is that smoking shisha is healthier than smoking cigarettes – there is a lack of knowledge about the harm smoking shisha causes which can be linked to the very limited amount of information on the packaging of shisha tobacco. Only a small number of shisha products comply with the guidelines on packaging and labelling as set out by the World Health Organisation (WHO). The principles behind the WHO’s guidelines are: “every person should be informed of the health consequences, addictive nature and moral threat of tobacco consumption and exposure to tobacco smoke5.” Shisha consumers rarely get to see the packaging in a café; the hookah, coals and shisha all come ready to smoke
Some shisha users do not realise they are smoking tobacco – this again links to the lack of clarity in a café environment.
The amount of nicotine, tar and other chemicals in shisha can vary significantly – consumers do not know what types of chemicals are involved or the level of potential harm they face6.
Legislation
The legislation that primarily deals with where shisha is smoked in Wales is the Smoke-free premises etc. (Wales) Regulations 20079. The distinction between an open public space and a closed environment is a much disputed debate in which several local authorities have tried to close shisha cafés10. To operate around the ban, café owners have constructed purpose built outdoor areas in which shisha can be smoked, complete with canopies, outdoor furnishing, lighting and heating11.
Comparison with cigarette use
There is no conclusive evidence regarding the level of harm shisha smoking causes in comparison to cigarettes. Because shisha is usually smoked in a social environment between 35 and 60 minute spells, research has indicated problems in comparing shisha and cigarette use7. Shisha users face many of the same health issues as cigarette smokers, such as the high levels of carbon monoxide consumed. Shisha users also face additional health issues from the toxins and heavy metals produced from burning charcoal. The sharing of hookah pipes can also lead to mouth infections. Shisha smokers generally inhale the smoke deeper into their lungs8.
What can be done?
Some areas in the UK have recognised the increasing popularity of shisha use and responded by releasing a number of useful recommendations:
Raising awareness on the harmful effects of shisha:
Delivering a public health message that shisha is extremely harmful and can be potentially responsible for a number of serious health conditions; raising the awareness of second hand smoke from shisha use, particularly for pregnant women and children
Health Checks
Incorporating shisha use questions into general health checks: Providing GPs, nurses and other health practitioners with the knowledge to ask about their patients’ shisha use
Smoking cessation
Giving shisha smokers the same opportunities to access smoking cessation services as cigarette smokers: Recognising the lack of specialist shisha cessation programmes, but offering shisha users a chance to access smoking cessation services
Labelling
Looking at the labelling of shisha products, so the packaging corresponds with contents of the product: Checking that health warning labels are in English and the contents of the product are fully listed on the packaging
1British Heart Foundation – Shisha Smoking
2American Lung Foundation – An emergining deadly trend: Waterpipe tobacco use. 2007
3Mohammed Jawad – All parliamentary group on smoking and health / Shisha
4British Heart Foundation – Shisha Smoking
5Nakkash R, Khalil J. Health warning labelling practices on nagrhile (shisha, hookah) waterpipe tobacco products and related accessories. Tobacco Control 2010; 19(3)235-239
6WHO Study Group on Tobacco Control Regulation Advisory Note: Waterpipe Tobacco Smoking: Health Effects, Research Needs and Recommended Actions by Regulators. WHO Geneva 2005
7Centers for Disease Control and Prevention – Hookah overview
8Mohammed Jawad – All parliamentary group on smoking and health / Shisha
9The Smoke-free Premises etc. (Wales) Regulations 2007
10Preston City Council – Thinking of setting up a shisha cafe? (download)
