ArticlePDF Available

Abstract

The hookah, a waterpipe, originated in India and became popular for smoking tobacco. It spread elsewhere and acquired other names like nargile, shisha, goza and hubble-bubble, before its popularity declined in India. A resurgence of hookah smoking is occurring in India and around the world, and is being promoted as safer than cigarette smoking. This article debunks this myth, by showing that hookah smoke contains more tar and carbon monoxide than cigarette smoke, promotes nicotine addiction and exposure to second-hand smoke, and causes gum disease, tuberculosis, chronic lung diseases, lung cancer, cardiovascular disease and low birth weight.
SPECIAL SECTION: TOBACCO CONTROL
CURRENT SCIENCE, VOL. 96, NO. 10, 25 MAY 2009
1319
Cecily S. Ray is in the Healis–Sekhsaria Institute for Public Health,
601, Great Eastern Chambers, 6th Floor, Plot No. 28, Sector 11, CBD
Belapur (E), Navi Mumbai 400 614, India.
e-mail: raycs@healis.org
GENERAL ARTICLE
The hookah – the Indian waterpipe
Cecily S. Ray
The hookah, a waterpipe, originated in India and became popular for smoking tobacco. It spread
elsewhere and acquired other names like nargile, shisha, goza and hubble-bubble, before its popu-
larity declined in India. A resurgence of hookah smoking is occurring in India and around the
world, and is being promoted as safer than cigarette smoking. This article debunks this myth, by
showing that hookah smoke contains more tar and carbon monoxide than cigarette smoke, pro-
motes nicotine addiction and exposure to second-hand smoke, and causes gum disease, tuberculo-
sis, chronic lung diseases, lung cancer, cardiovascular disease and low birth weight.
Keywords: Disease consequences, hookah, second-hand smoke, tobacco use, youth.
Origin, spread and decline of hookah smoking
HOOKAH smoking has been practised in India for over
400 years. The use of the hookah for tobacco smoking
originated in the court of Emperor Akbar in the late 16th
century, as a way of reducing potential harm from smoking,
on the suggestion of royal physicians, as tobacco was then
an unknown substance. In a small bowl at the top, tobacco,
flavoured with molasses was kept smouldering with burn-
ing charcoal. When the smoker puffed on the hookah, the
smoke passed down through a tube and then through a jar
of water before being inhaled
1
.
As the use of tobacco spread in India, the hookah
became the most prevalent form of smoking tobacco (also
used by some people for smoking opium and hashish).
Different forms of hookah were created to suit all social
classes. Used by both men and women, the practice of
hookah smoking became popular in areas where the
Mughals had a strong influence and became a part of the
culture
1
. When the British came to India with the East
India Company, some of them adopted the practice for a
while, for social acceptance, as it was a fashion, until
other forms of smoking largely replaced it
2
.
From 1950 to the early 1980s in India, bidi and ciga-
rette rose in popularity, as hookah smoking declined
3
.
Epidemiologic support for a decline in the prevalence of
hookah smoking is available from two studies in border-
ing districts of northern Bihar. In a survey of 10,340
individuals aged 15 years and above, conducted in 1968
in 16 villages in Darbhanga District (selected by random
sampling)
4
, the prevalence of hookah smoking was 14%.
In a house-to-house survey conducted in Akhta village,
Sitamarhi District, in the year 2000, the prevalence of
hookah smoking
5
was <5%. The authors compared the
two surveys and concluded that hookah smoking in the
population had reduced considerably.
From India, the hookah may have first spread to Persia,
where it was called narghile
6
and later, it spread to Tur-
key in the early 17th century, then the centre of the Otto-
man Empire. Eventually, the Narghile Café came up
where tea and coffee were also served. This fashion even-
tually saw a decline, but is being slowly revived in new
forms
7
. The narghile also spread to North Africa and
Saudi Arabia, where it was called shisha (glass bottle) or
goza, and to the Far East, especially China and the Philip-
pines
8
.
Recent revival of waterpipe smoking
A revival of the narghile has occurred from the late 1990s
or even earlier in parts of West Asia, northern Africa and
South East Asia (especially India and Indonesia) and has
spread to parts of Europe, Russia and North America. At
least in some areas, its revival is linked to the people of
West Asian origin and to restaurants run by them. Local
enthusiasm for West Asian-style food has led to a growing
interest in hookah smoking as well. The tobacco industry
has picked up on the trend and introduced new flavour-
ings to waterpipe tobacco, such as fruit, chocolate, mint
etc., to appeal to the youth and women. Advertising on
the internet uses the link to an old tradition and an exotic
appeal.
Due to the revival of the waterpipe worldwide, concern
is mounting internationally about the potential disease
fallout.
SPECIAL SECTION: TOBACCO CONTROL
CURRENT SCIENCE, VOL. 96, NO. 10, 25 MAY 2009
1320
Target market
The revival of the waterpipe is market-driven and the tar-
get group is young adults, including women. This does
not deter some underage youth as well from experiment-
ing with it. The setting is specialized parlours, bars, cafés
or restaurants that offer the option of smoking a hookah.
An alternative is smoking at home after joining web-
based clubs or forums (based in various countries), where
information about hookah smoking, alluring advertise-
ments, on-line ordering facilities and space for customers
to contribute their comments is provided. Hookah smok-
ing has taken-off well with the target group, as it provides
a social setting, an activity and novelty rolled into one,
along with a manufactured illusion of relative harmless-
ness. Peer pressure and the desire for social acceptance
are other factors. While some of these websites do men-
tion the hazards, other websites and blogs refer to this
practice as a lighter, less harmful or even non-addictive
way of smoking or form of smoking, even where some of
the risks are admitted
8,9
.
Dynamics in Mumbai, India
A recent proliferation of hookah parlours has occurred in
Mumbai. The current Mayor, also a physician, reported
receiving many phone calls from parents from all walks
of life and communities to complain about the hookah
parlours. The Mayor then decided to visit a few of them.
Following this, the Municipal Corporation decided to order
the closure of these parlours and announced that restau-
rants offering the hookah would not be permitted to re-
new their licences. This was based on a local rule that
eateries are prohibited from offering anything harmful to
their guests
10
. Hookah smoking in restaurants is also a
source of second-hand smoke and violates the law against
smoking in public places (the Cigarettes and Other To-
bacco Products Act, 2004), unless carried out in a sepa-
rate room where no food is served. According to a news
report, there may be around 59 hookah bars in Mumbai
11
.
The restaurants have challenged these decisions in the
Bombay High Court. Ahmedabad and Chandigarh are
other cities in India also taking action against hookah
bars.
Prevalence in India
Due to the earlier decline in waterpipe smoking, few sci-
entific reports are available on its health consequences.
Also, due to the relatively recent revival, few studies are
available on the prevalence of waterpipe smoking in India
or anywhere in the world.
In India, John
12
reported the household prevalence
from the National Sample Survey, 2000: 2.6% of rural
and 0.4% of urban households in India consume hookah
tobacco this primarily reflects lingering usage from the
previous epidemic. In a survey of urban slums in Farida-
bad, Uttar Pradesh, use of the hookah has been reported
among women (around 1.5%, i.e. 22% of the 7% women
smokers)
13
.
An earlier cross-sectional study conducted in 1977 in a
village near Bhiwani, Haryana, hookah smoking was in-
vestigated. Among the 278 men above 15 years of age
screened (82% participation rate), 70% (197) were cur-
rent smokers, among whom 50% (98) exclusively smoked
the hookah, 28% (56) exclusively smoked the bidi and
22% (42) smoked both. There were smokers in all the age
groups, except men over 71 years
14
.
Smoking practice
Hookah smokers in the Bhiwani study each consumed on
an average 50–100 g tobacco per day a tobacco mixture
used for hookah smoking. Half the amount of tobacco
used consisted of jaggery (molasses), which was added to
the tobacco for flavour. The hookah was customarily
smoked in a group of 6–10 persons, who shared the same
instrument. In view of this sharing, it was not possible
to accurately assess each individual’s tobacco consump-
tion
14
.
In current times, a hookah smoking session typically
lasts 45 min to 1 h, but may last up to several hours
15
.
From all accounts, this seems similar to how hookah
smoking has traditionally been practised.
Composition and toxic constituents
Waterpipe tobacco is grown and manufactured in India
and in some West Asian countries. The composition of
waterpipe tobacco is variable and not standardized
15
. Most
waterpipe tobacco is mixed with a sweetening agent, like
molasses (jaggery), honey, dried fruits or even glycerin.
Increasingly, other flavouring essences are also added.
Occasionally other drugs are added, like alcohol or hash-
ish. Available studies on waterpipe emissions are mostly
from Lebanon.
Nicotine delivery
A Lebanese study found that in a single standardized water-
pipe smoking session, the yield was 2.94 mg nicotine,
802 mg tar, 145 mg CO and greater quantities of poly-
aromatic hydrocarbons (PAHs) relative to the smoke of a
single cigarette. In comparison to cigarette smoking this
works out to at least 10–50% more than the amount of
nicotine, at least 30 times the amount of tar and at least
ten times the amount of CO. This could imply that to get
the same nicotine satisfaction for the amount in one ciga-
rette, one has to be exposed to much more CO and tar
while smoking a waterpipe
16
.
SPECIAL SECTION: TOBACCO CONTROL
CURRENT SCIENCE, VOL. 96, NO. 10, 25 MAY 2009
1321
Nicotine absorption
Combined human absorption data from 117 adults in four
studies (from Lebanon, Jordan, Kuwait and India) ana-
lysed together showed that daily use of the waterpipe
produced a nicotine absorption rate equivalent to smoking
ten cigarettes/day (95% Confidence Interval (CI) = 7–13
cigarettes/day), as measured by a 24 h urinary cotinine
level of 0.785 μg/ml (95% CI = 0.578–0.991 μg/ml).
Even among subjects who did not smoke the waterpipe
daily, a single session of waterpipe use produced a uri-
nary cotinine level equivalent to smoking two cigarettes
in one day. Researchers have concluded that daily water-
pipe use would be an effective means of initiating and
maintaining nicotine addiction. They have suggested that
more research needs to be done to find out whether
waterpipe use is a gateway to cigarette smoking or vice
versa
17
.
Carbon monoxide and carcinogens
Two well-known charcoal emissions are CO and PAHs.
In Lebanon, a study compared the emissions from a
machine-smoked waterpipe, first using the traditional
charcoal and then using an electric heating element. It
was found that about 90% of the CO and 75–92% of the
four- and five-membered ring PAH compounds origi-
nated in charcoal. More than 95% of the benzo(a)pyrene
in the smoke was attributable to charcoal
18
.
Analysis of smoke condensates from a waterpipe col-
lected on fibreglass filters revealed that a single narghile
smoking session delivers approximately 50 times the car-
cinogenic four- and five-membered ring PAHs as a single
standard cigarette
19
. Hence tar is qualitatively different
from that produced by cigarettes, as most of it comes
from the burning charcoal, and it is much higher in quan-
tity.
Use of a plastic hose, when compared to a highly per-
meable leather one, more than doubled the CO yield,
while the nicotine yield did not change much
20
.
Heavy metals
In another study on waterpipe emissions, higher levels of
arsenic, chromium and lead were found in comparison
with smoke from a single cigarette
21
.
Summary of toxic exposures from waterpipes
The CO and PAH emissions from waterpipes are much
higher than those of cigarettes. The nicotine delivery is
somewhat higher than that of one cigarette spread over a
longer duration of time. Heavy metals are another hazar-
dous component of waterpipe smoke. While nicotine, the
alkaloid people smoke tobacco for, is miscible in
water
22
, PAHs which are carcinogenic, are largely water
insoluble
23
the waterpipe cannot remove any significant
portion of them from the smoke.
Health hazards
There are few epidemiological studies documenting the
adverse health consequences of waterpipe smokers, since
the practice had declined to a low level in most parts of
the world, where it was popular earlier. Studies from India
are reported here, with a few other studies where there
are gaps in information.
Addiction
The high levels of nicotine absorption from waterpipe
smoking
17
are likely to quickly lead to addiction, which
users could maintain using cigarettes or bidis when a
waterpipe is not available. Studies on youth addiction to
nicotine through waterpipe use are needed.
Gum disease
In a cross-sectional study in Saudi Arabia among 262 parti-
cipants aged 17–60 years, periodontal disease measured
in terms of probing depth was found associated with both
waterpipe and cigarette smoking, The prevalence of
periodontal disease defined as a minimum of ten sites
with a probing depth of 5 mm was 19.5% in the total
population, 30% in waterpipe smokers, 24% in cigarette
smokers and 8% in non-smokers. The relative risk for
periodontal disease was 5.1 and 3.8-fold higher in water-
pipe and cigarette smokers respectively, compared to
non-smokers (P < 0.001 and P < 0.05 respectively)
24
.
Tuberculosis
In Storstroem County, Denmark, the incidence of tuber-
culosis has been increasing since 1990, both among Dan-
ish citizens and the immigrants. The increase in patients
born in Denmark has been seen mainly among younger
males. When contacts of index patients were traced, shar-
ing a waterpipe with a patient was found to be a risk fac-
tor for infection, as confirmed by Mantoux test
25
.
Chronic lung diseases
Among 300 men (150 smokers and 150 non-smokers) in
Chandigarh, between the ages of 55 and 85, in a case-
control study on the long-term effects of smoking on
pulmonary function, the 32 exclusive hookah smokers
had airflow parameters comparable to the heavy bidi
and/or cigarette smokers. In this study, only the heavy
SPECIAL SECTION: TOBACCO CONTROL
CURRENT SCIENCE, VOL. 96, NO. 10, 25 MAY 2009
1322
smokers had significant worsening of the airflow parame-
ters. Measurements included forced vital capacity (FVC),
forced expiratory volume in the first second (FEV
1
),
FEV
1
ratio (FEV
1
/FVC × 100), forced expiratory flow
between 25 and 75% of the vital capacity forced expira-
tory flow at 80% of FVC and the time taken to expel 50%
of the FVC. The values were also corrected for height and
weight
26
.
In the cross-sectional study in a village in Haryana,
where 278 males ( 15 yrs) were screened for chronic
respiratory disease of non-specific origin, symptoms of
chronic respiratory disease, including cough, phlegm,
shortness of breath, wheezing and frequent chest illness,
as well as ventilatory abnormalities, were common in the
subjects, the majority of whom were smokers; and mostly
hookah smokers. Diagnosis of chronic bronchitis was
more in smokers compared to non-smokers. The major
causative agent in this community was smoking, particu-
larly hookah smoking
14
.
In a house-to-house survey for chronic bronchitis in
three villages in Jhansi, Uttar Pradesh, where 1424 men
and women aged 20 years and above were clinically
examined, 92 cases of chronic bronchitis were detected.
Prevalence of chronic bronchitis was highest among chi-
lum or hookah smokers (85 per 1000), which was almost
twice as high as that among the bidi or cigarette smokers
(46 or 43 per 1000 respectively)
27
.
Studies from Saudi Arabia and Turkey have shown
similar results
15
. It may be safely concluded that hookah
smoking is an even more powerful cause of lung
damage and chronic bronchitis than cigarette and bidi
smoking.
Lung cancer
Twenty-five cases of cyto-histologically confirmed bron-
chogenic carcinoma diagnosed in a hospital in Srinagar
between 1970 and 1972 were reviewed. All were males
between the ages of 40 and 80 years. Only three patients
denied a history of smoking. Among the 22 (88%) smok-
ers, 17 smoked the hookah, three smoked both the hookah
and cigarettes and two smoked only cigarettes
28
. In Paki-
stan, an earlier study had observed a close association
between hookah smoking and carcinoma of the lung
29
. On
the basis of these two studies and knowledge of the car-
cinogenic nature of tobacco smoke, it is clear that hookah
smoking causes lung cancer.
Cardiovascular disease
The high concentration of CO in the smoke of the water-
pipe, is likely to cause cardiovascular disease and
heart attacks. A case control study from Lebanon has
reported that ever smokers of the narghile had double the
risk of coronary heart disease compared to never smok-
ers
15
.
Reproductive outcomes
Recent cohort studies of pregnant women in Lebanon
showed a twofold odds ratio for low birth weight among
women who smoked narghile
30–32
.
Second-hand smoke
Waterpipe smoking poses a significant hazard of sus-
pended particulates to non-smokers by way of second-
hand smoke, of a similar nature as that of cigarettes
33
.
Relevant policies
As a policy, the Indian government promotes tobacco
growing and export, for revenue and foreign exchange.
Hookah tobacco is an important tobacco product export
from India. A total of 10,656 t of hookah paste were
exported in 2007–08, representing one-third (34.7%) of
the quantity of tobacco products exported and 8.4% of the
value
34
.
The attraction of the youth to waterpipe smoking,
including underage youth, is the most important reason
for concern in the health community and the government,
since addiction to tobacco in youth can lead to lifelong
addiction and adverse health consequences. Hookah
smoking could also become a gateway to cigarette smok-
ing. The revival of hookah smoking in India calls for
effective policies to curb it.
In India, the Cigarettes and Other Tobacco Products
Act, 2003, bans smoking in most public places, and re-
stricts smoking to a separate room in restaurants. This
works as a loophole for the hookah parlours. Other
aspects of the Act which apply to hookah parlours are the
prohibition on the sale of tobacco within 100 yards of
educational institutions and sale to minors; prohibition on
advertising, except at the point of sale, and health warn-
ings. A suitable plan for providing health warnings for
hookah tobacco and hookah smoking needs to be worked
out, as users are unlikely to see the packaging.
Conclusion
While there are only a few scientific studies on waterpipe
smoking (on contents, delivery, absorption and epide-
miology), they are sufficient, along with data on cigarette
and bidi smoking, to demonstrate that this practice is
hazardous in nature. The 400-yr-old hopeful idea that the
waterpipe could make tobacco smoking safe, has thus
been debunked. No doubt should remain that hookah
smoking is quite risky in terms of causing addiction to
nicotine as well as several illnesses: chronic bronchitis,
lung cancer, and adverse reproductive outcomes. Hookah
smoking may lead to cigarette smoking and a lifelong
addiction to smoking tobacco, which leads to smoking-
SPECIAL SECTION: TOBACCO CONTROL
CURRENT SCIENCE, VOL. 96, NO. 10, 25 MAY 2009
1323
related diseases. Men and women, especially teens and
youth, would do well to keep away from smoking the
waterpipe. State and local governments need to be vigi-
lant and prohibit the practice in public establishments in
order to protect the youth, who are the main targets.
Parents also have an important role to play in teaching
their children about the hazards of hookah smoking and
tobacco use in general. They also have an important role
to play in helping their children find constructive outlets
for their energy and safe spaces in which to enjoy leisure
time. Keeping the home open to discussion as well as for
supervized informal social gatherings is another aspect of
prevention of bad habits in adolescents.
1. Historical records and anecdotes: from the middle ages to the
modern times. In Report on Tobacco Control in India (eds Reddy,
K. S. and Gupta, P. C.), Ministry of Health and Family Welfare,
Government of India, 2004, pp. 7–18; http://www.whoindia.
org/SCN/Tobacco/Report/TCI-Report.htm
2. Hookah. Wikipedia. http://en.wikipedia.org/wiki/Hookah
(ac-
cessed on 19 December 2008).
3. Sanghvi, L. D., Challenges in tobacco control in India: a historical
perspective. In Control of Tobacco-Related Cancers and Other
Diseases (eds Gupta, P. C., Hamner III, J. E. and Murti, P. R.),
Oxford University Press, Bombay, 1992, pp. 47–56.
4. Mehta, F. S. et al., Report on investigations of oral cancer and
precancerous conditions in Indian rural populations. 1966–69,
Munksgard, Copenhagen, 1971, p. 120.
5. Sinha, D. N., Gupta, P. C. and Pednekar, M. S., Tobacco use in
rural area of Bihar, India. Indian J. Commun. Med., 2003, 28,
167–170.
6. Fumari (homepage on the Internet). Hookah tobacco, pipes and
more; http://www.fumari.com/hookah-history (accessed on 19 De-
cember 2008).
7. Narghile (homepage on the Internet). http://www.business-with-
turkey.com/tourist-guide/narguile_nargile_narghile.shtml (accessed
on 19 December 2008).
8. The Hookah Lounge (homepage on the internet). http://www.
thehookahlounge.org/2006/06/30/narghile/
(accessed on 19 De-
cember 2008).
9. The Hookah Domain (homepage on the internet). http://
www.hookahdomain.com
/ (accessed on 19 December 2008).
10. Silvano, S., Mayor of Mumbai wins war against hookah parlours.
Tobacco Kills, 2008, 3, 14–17.
11. Desai, S. and Shah, J., Minister asks why hookah parlours still
open, BMC vows to enforce ban. Indian Express, 10 March 2009;
http://www.expressindia.com/latest-news/minister-asks-why-
hookah-parlours-still-open-bmc-vows-to-enforce-ban/432887/
12. John, R. M., Household’s tobacco consumption decisions: evi-
dence from India. J. South Asian Develop., 2006, 1, 119–147.
13. Anand, K., Shah, B., Yadav, K., Singh, R., Mathur, P., Paul, E.
and Kapoor, S. K., Are the urban poor vulnerable to non-
communicable diseases? A survey of risk factors for non-
communicable diseases in urban slums of Faridabad. Natl. Med. J.
India, 2007, 20, 115–120.
14. Malik, S. K. and Singh, K., Smoking habits, chronic bronchitis
and ventilatory function in rural males. Indian J. Chest Dis. Allied
Sci., 1978, 20, 73–79.
15. Knishkowy, B. and Amitai, Y., Water-pipe (narghile) smoking: an
emerging health risk behavior. Pediatrics, 2005, 116, e113–e119;
http://pediatrics.aappublications.org/cgi/reprint/116/1/e113
16. Shihadeh, A. and Saleh, R., Polycyclic aromatic hydrocarbons,
carbon monoxide, ‘tar’, and nicotine in the mainstream smoke
aerosol of the narghile water pipe. Food Chem. Toxicol., 2005, 43,
655–661.
17. Neergaard, J., Singh, P., Job, J. and Montgomery, S., Waterpipe
smoking and nicotine exposure: a review of the current evidence.
Nicotine Tob. Res., 2007, 9, 987–994.
18. Monzer, B., Sepetdjian, E., Saliba, N. and Shihadeh, A., Charcoal
emissions as a source of CO and carcinogenic PAH in mainstream
narghile waterpipe smoke. Food Chem. Toxicol., 2008, 46, 2991–
2995.
19. Sepetdjian, E., Shihadeh, A. and Saliba, N. A., Measurement of 16
polycyclic aromatic hydrocarbons in narghile waterpipe tobacco
smoke. Food Chem. Toxicol., 2008, 46, 1582–1590.
20. Saleh, R. and Shihadeh, A., Elevated toxicant yields with narghile
waterpipes smoked using a plastic hose. Food Chem. Toxicol.,
2008, 46, 1461–1466.
21. Shihadeh, A., Investigation of mainstream smoke aerosol of the
argileh water pipe. Food Chem. Toxicol., 2003, 41, 143–152.
22. http://en.wikipedia.org/wiki/Nicotine
23. Rubin, H., Synergistic mechanisms in carcinogenesis by poly-
cyclic aromatic hydrocarbons and by tobacco smoke: a bio-
historical perspective with updates. Carcinogenesis, 2001, 22,
1903–1930; http://carcin.oxford-journals.org/cgi/content/full/22/
12/1903
24. Natto, S., Baljoon, M. and Bergstrom, J., Tobacco smoking and
periodontal health in a Saudi Arabian population. J. Periodontol.,
2005, 76, 1919–1926.
25. Steentoft, J., Wittendorf, J. and Andersen, J. R., Tuberculosis and
water pipes as source of infection. Ugeskr. Laeg., 2006, 168, 904–
907.
26. Dhand, R., Malik, S. K. and Sharda, P. K., Long term effects of
tobacco smoking: results of a spirometric study in 300 old men.
Indian J. Chest Dis. Allied Sci., 1985, 27, 44–49.
27. Nigam, P., Verma, B. L. and Srivastava, R. N., Chronic bronchitis
in an Indian rural community. JAPI, 1982, 37, 277–280.
28. Nafae, A., Misra, S. P., Dhar, S. N. and Ahmad Shah, S. N., Bron-
chogenic carcinoma in Kashmir valley. Indian J. Chest Dis., 1973,
15, 285–295.
29. Ibrahim, M., Bronchogenic carcinoma in East Pakistan. Dis.
Chest., 1954, 26, 286–294.
30. Tamim, H., Yunis, K. A., Chemaitelly, H., Alameh, M. and Nas-
sar, A. H., National Collaborative Perinatal Neonatal Network
Beirut, Lebanon. Effect of narghile and cigarette smoking on new-
born birthweight. BJOG, 2008, 115, 91–97.
31. Bachir, R. and Chaaya, M., Maternal smoking: determinants and
associated morbidity in two areas in Lebanon. Matern. Child
Health J., 2008, 12, 298–307.
32. Nuwayhid, I. A., Yamout, B., Azar, G. and Kambris, M. A., Nar-
ghile (hubble-bubble) smoking, low birth weight, and other pre-
gnancy outcomes. Am. J. Epidemiol., 1998, 148, 375–383.
33. Maziak, W., Rastam, S., Ibrahim, I., Ward, K. D. and Eissenberg,
T., Waterpipe-associated particulate matter emissions. Nicotine
Tob. Res., 2008, 10, 519–523.
34. Tobacco Board, Review on exports of Indian tobacco and tobacco
products. 2007–08, Guntur, 2008; http://www.indiantobacco.
com/review_exports_2007_08.pdf
(accessed on 15 December
2008).
ACKNOWLEDGEMENTS. This work was supported by Physicians
for Smoke-free Canada, Ontario, Canada. I thank Dr Prakash C. Gupta
for providing references with epidemiological evidence for the decrease
in prevalence of hookah smoking.
... Hookah smoke also contains carbon monoxide due to the use of charcoal. [21] CHUTTA It is a type of small cigars in which a tobacco leaf is rolled into a cylindrical shape and tied at one end. [19] KHAINI It is sun-dried tobacco with slaked lime, cardamom, menthol, and other flavorings. ...
... [19] In addition, hookah causes carbon monoxide poisoning and transmission of tuberculosis, herpes, and hepatitis. [21] Depending on the frequency of hookah smoking per session, a person inhales more nicotine and other harmful products of tobacco than cigarette smoking which has immediate effects on the heart. [21] ...
... [21] Depending on the frequency of hookah smoking per session, a person inhales more nicotine and other harmful products of tobacco than cigarette smoking which has immediate effects on the heart. [21] ...
Article
Full-text available
The aim of our review is to have a complete description of tobacco right from its origin, prevalence, composition, health hazards, and preventive measures. Tobacco is a well-known etiology for causing precancerous and cancerous diseases, which kills nearly 7 million people worldwide every year. In this review, we would like to brief the patterns and prevalence of tobacco use, forms and composition of tobacco use, health hazards of tobacco use, and tobacco control and preventive measures. As a dentist, we play a pivotal role in educating smokers and help them to withdraw their habits. It is essential for all the dentist to undergo a mandatory tobacco cessation training program to motivate the tobacco users to abstain themselves from their habits and to help the community as a whole in reducing the global disease burden. Tobacco causes addiction, cancer of the lung, larynx, oral cavity, pharynx, esophagus, stomach, pancreas, liver, kidney, urinary bladder and cervix, and myeloid leukemia. The oral effects of tobacco include discolorations of teeth and restorations, c/hairy tongue, reduced ability to taste and smell, smokers' melanosis, smokers' palate, dental caries, oral candidosis, increased failure rates for dental implants, periodontal disease, smokers' white patch/leukoplakia, and oral cancer.
... It is less addictive which is a misconception 27,28,29 In fact, hukkah is more risk prone than cigarette due to higher amount of carbon monoxide poisoning, tar of heavy metals and carcinogens. 30 It causes lung cancer, cardiovascular disorders and low weight of new born 31 The blood nicotine in hukkah smokers is equal to ten cigarettes smoked per day. 32 A study was conducted among the student population of Israel wherein it was found that 41% of students smoked tobacco through hukkah 33. ...
... 6 Later, Ray, C.S. (2009) highlighted the need of exposure to the fact that the more than 400-yr-old hopeful idea that the waterpipe could make tobacco smoking safe is incorrect, rather it is quite risky in terms of causing addiction to nicotine as well as several illnesses. 21 The study reveals that the prevalence of anaemia is high for aged women of rural Haryana, and it was higher for the hookah smokers. Kaur and Kochar (2009) in their study among the 'Jat' women in rural Haryana found a very higher prevalence (97%) of anaemia. ...
Article
Full-text available
Hookah smoking is an age-old tradition prevalent among the rural population of India. It is quite risky in terms of causing addiction to nicotine as well as several illnesses. This study offers to find out the association of hookah smoking with geriatric anaemia. Cross-sectional survey was conducted to collect data on 206 elderly women of the Palwal district of Haryana, North India. Prevalence of hookah smoker was 36.4% and it is projected to rise with the increasing age. The prevalence of anaemia (69.4%) was also high among this geriatric population. Present study found that hookah smoking is significantly correlated with geriatric anaemia (r=0.472, p <0.01). Result reveals that hookah smoker are about 11 times more likely to develop anaemia (OR:11.2, 95% CI: 5.33-23.53). This study highlighted the need for more effective tobacco control policies and awareness programme in rural villages of India to prevent the health hazards related to smoking.
... The hookah, also known as a water pipe, narghile, arghile, or shisha, was invented in the 16th century as an attempt to purify smoke through water [1]. Nowadays hookah smoking is becoming popular in developing countries as well as in Western countries, especially among the young [2][3][4]. ...
Article
Full-text available
The American Heart Association has published a scientific statement on the effect of hookah smoking on health outcomes; nevertheless, hookah smoking continues to be popular worldwide, especially among the young. Recent reports mention a potential link between hookah smoking and obesity; however, uncertainties still surround this issue. The aim of the current study was to conduct a systematic review to clarify whether hookah smoking is associated with a higher risk of obesity among the general population. This study was conducted in compliance with the preferred reporting items for systematic reviews and meta-analyses (PRISMA) guidelines, and data were collated by means of a meta-analysis and a narrative synthesis. Of the 818 articles retrieved, five large-population and low-bias studies comprising a total of 16,779 participants met the inclusion criteria and were reviewed. All included studies reported that, regardless of gender, hookah smoking increases the risk of obesity among all ages and observed an association between the two after a correction for several confounders or reported a higher prevalence of obesity among hookah smokers. This was confirmed by the meta-analysis. Therefore, hookah smoking seems to be associated with a higher risk of obesity. Public health policymakers should be aware of this for the better management of obesity and weight-related comorbidities.
... Peer pressure and the desire for social acceptance are other factors. [17] Given the social nature of hookah use and online advertising of growing hookah venue businesses, the aim of this study was to assess the content of online retail markets offering Hookah products in India. ...
Article
Full-text available
Introduction: Hookah smoking is becoming increasingly popular among the youth. Evidence shows that exposure to marketing of the unhealthy products through social media platforms may impact adolescent health behaviors. The aim of the study was to perform a content analysis of online portals selling hookah products. Materials and methods: A content analysis of online retail market was conducted on Google India using three keywords hookah, hookah products, and shisha. Retail websites popular in India that were selling hookah products were randomly selected and explored. A total of 15 themes were developed and used to describe various promotional strategies for hookah products. Results: In all, 41 (19.2%) products claimed to be tobacco/nicotine-free and only 14 products (6.5%) displayed age/health-specific warnings. About 86% of products were available at discounted rates; glamorizing words for describing products in form of superior, premium, and legendary were found on 189 (88.3%) products. Phrases such as "ultimate way to celebrate," "perfect excuse to chill with your friends," and "now enjoy the world of smoking without any doubt of harm" are commonly used to promote hookah products. Conclusion: Easy availability of newer forms of smoking at online markets could play a role in promoting the use of hookah among the youth. Most products are being sold without any warnings and there is no means to control the selling of the products to minors. There is a need to raise the issue of hookah products in the same tune as done for other forms of tobacco.
... Pregnancy outcomes, including lower birth weight and intrauterine growth retardation, Sudden infant death syndrome and decreased lung function are more frequent among women who smoke than among those who do not smoke. [11] ORAL EFFECTS OF TOBACCO USE Tobacco in any form, either smoked or smokeless, can cause a wide spectrum of oral mucosal alterations or lesions. It may cause tooth stains, abrasions, smoker's melanosis, acute necrotizing ulcerative gingivitis, nicotinic stomatitis, keratotic patches, black hairy tongue, palatal erosions, and oral carcinoma. ...
Article
Full-text available
The emergence of the epidemic of nicotine addiction in India and other nations is a global public health tragedy of untoward proportions. Smoking or chewing tobacco can seriously affect general, as well as oral health. Smoking-caused disease is a consequence of exposure to toxins in tobacco smoke and addiction to nicotine is the proximate cause of these diseases. This article focuses on nicotine as a determinant of addiction to tobacco and the pharmacologic effects of nicotine that sustain cigarette smoking. The pharmacologic reasons for nicotine use are an enhancement of mood, either directly or through relief of withdrawal symptoms and augmentation of mental or physical functions. Tobacco cessation is necessary to reduce morbidity and mortality related to tobacco use. Strategies for tobacco cessation involves 5A's and 5R's approach and pharmacotherapy. Dental professionals play an important role in helping patients to quit tobacco at the community and national levels, to promote tobacco prevention and control nicotine addiction. Dentists are in a unique position to educate and motivate patients concerning the hazards of tobacco to their oral and systemic health, and to provide intervention programs as a part of routine patient care.
Article
Full-text available
The rise in population is driving up the global food demand, which, in turn, influences the processing of foods that leads to the ample generation of waste material throughout the world. Molasses is one of the wastes generated from the sugarcane processing industry by repeated crystallization during sugar preparation. The yield varies from 2.2 to –3.7% per tons of sugarcane. Due to its composition and economic importance, it is the major choice (as a carbon source) for food, feed and fermentation industries in the fructification of ethyl alcohol, liquor (rum), dry yeast, acetone, butanol, certain organic acids, etc. However, the on-going scenario of global research, the largest quantity of molasses is being utilized for the manufacture of ethanol. Traditionally, this is used for the manufacture of hukas, tobacco and liquors. However, due to its improper management, such as storage, packaging and transportation, the entire production of molasses is not being commercially utilized. It possesses numerous health benefits, such as antioxidant, anti-obese, anti-cancerous, antimicrobial, anti-anaemic, improves bone and hair health, used for the treatment of skin and anaemia. The present review is aimed to enlighten the composition, types of molasses, its respective utilization (traditional/conventional), health benefits and regulations.
Article
Full-text available
BACKGROUND. Globally, tobacco ranks as one of the major risk factors for death, disease and disability. While strong measures have been implemented to reduce cigarette use, there are alternative ways to smoke tobacco, such as the hookah pipe. Hookah pipe use appears to pose a significant public health concern and has serious short- and long-term health consequences for users and those exposed to second-hand smoke. To date, few studies have reviewed hookah pipe interventions beyond the efficacy-based paradigm. OBJECTIVES. To systematically review interventions aimed at reducing hookah pipe use through the RE-AIM framework (reach, efficacy, adoption, implementation and maintenance of results) in order to provide a practical means of evaluating interventions. METHODS. A systematic review spanning 12 databases identified studies aimed at reducing hookah pipe use. All methodological types of intervention studies that were peer reviewed and in the English language were considered for inclusion. The quality of each study was assessed. Ten studies were deemed eligible. For each study, data were extracted using the RE-AIM framework. RESULTS. All studies focused solely on the smoker, and their recruitment strategies were described. Eight studies reported meeting their objectives. Overall, the studies presented limited information regarding adoption success. The interventions were mainly supportive, educational or counselling sessions. Only five studies reported on the maintenance of results post intervention. CONCLUSIONS. Interventions focusing on reducing hookah pipe use are limited. Counselling and educational support sessions seem to be the most feasible and potentially successful approaches for intervention.
Article
Full-text available
Research question: What is the extent of tobacco use in a rural area of Bihar, India. Objective: To study tobacco use in rural area of Bihar. Study design: Cross-sectional. Setting: A rural area in Bihar, India. Participants: All the residents of Akhta village, Sitamarhi district of Bihar. Study variables: Tobacco use, age, gender, socioeconomic status. Statistical analysis: Percentage, chi-square test. Results: The response rate was 91%. The non-response was due to houses being locked during the period of survey. Among 3566 children (<15 years), smokeless tobacco use was 6.2% and smoking 0.3%. Most smokeless tobacco use was in the form of red toothpowder (77%). Smokeless tobacco use among adults (male 2910; female 2586) was 32.7% (42.6% males, 21.7% females). Khaini (57.1%) among males and tobacco toothpowder (41.3%) among females were the most commonly used smokeless tobacco products. Smoking prevalence was 27.7% (31.6% males, 23.4% females). The most prevalent form (>80%) was bidi smoking both in men and women. Conclusion: Tobacco use among adult residents of Akhta village was quite high. Smoking prevalence among females was high even though smoking by women is considered as taboo in Indian society. Intervention measures need to be urgently explored.
Article
Full-text available
Narghile smoking, a common habit among women in many non-Western societies, is assumed by the public to be minimally harmful. This study aims at identifying the effect of smoking narghiles during pregnancy on the weight of the newborn and other pregnancy outcomes. Three groups of pregnant women were interviewed in several hospitals in Lebanon between 1993 and 1995: 106 who smoked narghiles during their pregnancy, 277 who smoked cigarettes, and 512 who did not smoke. The adjusted mean birth weight of babies born to women who smoked one or more narghiles a day during pregnancy and to women who started smoking in the first trimester was more than 100 g less than that of babies born to nonsmokers (p < 0.1). The adjusted odds ratio of having babies with low birth weight (<2,500 g) among the narghile smokers was 1.89 (95% confidence interval (CI) 0.67-5.38). The risk increased to 2.62 (95% CI 0.90-7.66) among those who started smoking narghiles in the first trimester. A stronger association and a dose-response relation were found among cigarette smokers. The association between narghile smoking and other pregnancy outcomes, especially Apgar score and respiratory distress, was also noticeable. Further research and a policy action to fight the misperception that narghile smoking is safe are both recommended.
Article
This article analyses consumption patterns, socio-economic distribution and household choice of a variety of tobacco products across rural and urban India. Using a multinomial logit model, we examine the choice behaviour of a household in deciding whether and which tobacco products to consume. Household-level data covering 120,309 households have been used for this. We find that most forms of tobacco consumption are higher among socially disadvantaged and low-income groups in the country. Variables such as education, sex ratio, alcohol and pan consumption were found to be significant factors determining tobacco consumption habits of Indian households. The effect of some of the factors on the probability of consumption differs for certain types of tobacco products, increasing some and decreasing others. Addictive goods such as alcohol and pan were found to be complementary to tobacco consumption.
Article
Objective To assess the effect of narghile smoking on the weight of newborns. Design Historical retrospective cohort. Setting Six major hospitals in Greater Beirut, Lebanon. Population Consecutive singleton newborns delivered from August 2000 to August 2003. Methods Obstetric and nursery charts were reviewed to obtain information about maternal and neonatal variables. Information concerning initiation of smoking, dose of smoking, smoking habits during pregnancy, and socio-demographic characteristics was collected through interviews with mothers. Main outcome measures Low birthweight and newborn birthweight. Results Exclusive narghile smokers constituted 4.4% (378/8592) of women. Multiparas were significantly more likely to smoke cigarettes and narghile. Mothers smoking narghile more than once per day were at 2.4 increased odds of having low birthweight infants compared with nonsmoking mothers (OR 2.4; 95% CI 1.2–5.0) after adjusting for confounding variables. No difference was noted between women smoking narghile in the first trimester and those initiating smoking in subsequent trimesters regarding low birthweight. Conclusions Narghile smoking more than once per day increases the odds of low birthweight by a 2.4-fold compared with nonsmokers, although to a lesser extent than cigarette smoking.
Article
Burning charcoal is normally placed atop the tobacco to smoke the narghile waterpipe. We investigated the importance of charcoal as a toxicant source in the mainstream smoke, with particular attention to two well-known charcoal emissions: carbon monoxide (CO) and polyaromatic hydrocarbons (PAH). CO and PAH yields were compared when a waterpipe was machine smoked using charcoal and using an electrical heating element. The electrical heating element was designed to produce spatial and temporal temperature distributions similar to those measured using charcoal. With a popular type of ma’assel tobacco mixture, and using a smoking regimen consisting of 105 puffs of 530 ml volume spaced 17 s apart, it was found that approximately 90% of the CO and 75–92% of the 4- and 5-membered ring PAH compounds originated in the charcoal. Greater than 95% of the benzo(a)pyrene in the smoke was attributable to the charcoal. It was also found that the relative proportions of individual PAH species, the “PAH fingerprint”, of the mainstream smoke were highly correlated to those extracted from the unburned charcoal (R2 > 0.94). In contrast, there was no correlation between the PAH fingerprint of the electrically heated and charcoal-heated conditions (R2 < 0.02). In addition to inhaling toxicants transferred from the tobacco, such as nicotine, “tar”, and nitrosamines, waterpipe smokers thus also inhale large quantities of combustion-generated toxicants. This explains why, despite the generally low temperatures attained in the narghile tobacco, large quantities of CO and PAH have been found in the smoke.
Article
PIP An evaluation of the clinical, radiological and cytohistological parameters of bronchogenic carcinoma was conducted using a sample of 25 male patients (40-80 years of age); 3 of the patients claimed they were not smokers; the rest were graded as mild/moderate/heavy smokers. The 'deep cough' method of repeated and meticulous cytologic examination of sputum samples was used to detect neoplasm. Respiratory symptoms (coughs with expectoration) were reported by 24 of the 25 cases. Bronchial biopsy in 19 cases confirmed malignancy of growth as diagnosed by bronchoscopy. Cytologic examination of sputum in 18 cases also confirmed malignant growth and illustrated the efficiency of exfoliative cytology over tissue histology. These findings support the close association between hukkah (Indian hubble bubble) smoking and lung cancer. Further research is needed however to better understand the role of hukkah smoking in the development of lung cancer.