The global tobacco epidemic may kill 10 million people annually in the next 20-30 years, with 70% of these deaths occurring in developing countries. Currentresearch, treatment, and policy efforts focus on cigarettes,while many people in developing regions smoke tobacco using waterpipes.

This centuries-old tobacco use method comes under many different names: “nargileh” is widely used in the Middle East, “hookah" is quite common in Asia and the English-speaking world, “shisha” fits first the North of Africa but it is also common in the Arab-Persian Gulf region and now, thanks to the world waterpipe craze, in every part of the globe. It also comes under different shapes and sizes with the term waterpipe implying a unifying feature of all these forms: the passage of smoke through water before inhalation by the smoke

Waterpipe smoking has increased dramatically worldwide in recent years, with an estimated 100 million daily users. Recent evidence shows that a quarter of some populations in the Eastern Mediterranean region currently smoke the waterpipe. This trend isworrisome because of tobacco's known harmful effects to human health. According to waterpipe smokers, the recent resurgence in waterpipe popularity is due to the introduction of maassel (a specially prepared tobacco with sweetened fruit flavors and mild aromatic smoke), the media, and social trends. Indeed, many social factors contribute in promoting the use of nargileh, because it is considered a recreational activity, indispensable in family and friend gatherings.
Smoking tobacco through a waterpipe generally is viewed in a more positive light than smoking cigarettes, especially by women, who are enthusiastic about what they viewed as the nargileh's positive aspects, including its traditional, familiar, social and attractive look. It remains to be seen, the possible role of resurgence of local identities in contrast to western culture in the adoption of this "oriental" method of smoking. The nargileh habit is dangerous, particularly to young people, as their first cigarette is usually smoked with friends, while their first nargileh is smoked with their parents and family members.

In a waterpipe, tobacco is heated by charcoal, and the resulting smoke is passed through a water-filled chamber, cooling the smoke before it reaches the smoker. While most waterpipe users believe that this method of smoking tobacco delivers less tar and nicotine than regular cigarette smoking and has fewer adverse health effects because of the filtering effect of the water, it is proved that nargileh smokers are exposed to the same chemicals that make cigarette smoke harmful. Some toxins appear at greater levels in nargileh smoke than in cigarette smoke, while others are more prevalent in cigarette smoke. However, neither is preferable to the other, as both have the potential to cause diseases. There is evidence linking waterpipe smoking to a variety of life threatening conditions, including respiratory, cardiovascular, and cancer diseases, and pregnancy related complications. Waterpipe smoking as well as cigarette smoking will produce harmful effects on the function of ventilatory capacity of smokers and increase the risk of developing obstructive airway disease. Since waterpipe smoke contains considerable amounts of the addictive substance nicotine, nicotine dependence can sustain the habit among experimenters creating a stable base of waterpipe smokers within the society and contributing further to its spread. The myth of the nargileh as a safer way of smoking is old.

It is difficult to indicate how many cigarettes equal one nargileh session. Both have different components and burn at different temperatures. Tar is more harmful if burned at a higher temperature, and because cigarettes and waterpipes burn at different temperatures, they cannot be equally harmful. The maximum temperature found in a nargileh head is considerably lower than the maximum temperature found in cigarettes. Moreover, there are also other important parameters that could change the amount and nature of the substances absorbed by the smoker: aspiration speed, pressure, water solubility of certain substances, volume of bowl, amount and temperature of water, added substances, length of the aspiration hose and others. Effective intervention strategies to curb this emerging public health problem must be developed as quickly as possible.

Béatrice CHAMI, MD
Chest Physician, Tobaccologist, MBA.