What's in a name? Tobacco in any form is deadly!

Shobha Shukla, Citizen News Service (CNS)

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CNS: citizen-news.org
Just as a rose would smell as sweet if called by another name, so also tobacco would spell disease and death no matter in which guise it is consumed. Globalization is changing the face of smoking, especially among the youth, and they are turning to alternative forms of tobacco (often referred to as Alternative Tobacco Products or ATPs) like e-cigarettes, water pipes and now the midwakh, even as cigarette smoking subsides. Presenters at the 16th World Conference on Tobacco Or Health (WCTOH 2015), held in Abu Dhabi, shared valuable information on the ill effects of ATPs and their ever increasing popularity during the last decade globally.


Dr Abdul Razzak Alkaddour, Head of Preventive Cardiology and Rehabilitation, Sheikh Khalifa Medical City, gave detailed insights about midwakh--the new enemy on the block.

Midwakh is a small pipe for smoking tobacco blend called dokha. Dokha (which means dizzy in Arabic) is a combination of tobacco leaves with a variety of barks, herbs, spices, dried flowers/fruit, henna, and unknown powdered adulterants.

Dr Razzak said: "Midwakh smoking is the second-most common form of tobacco used, (after cigarettes) among men in Abu Dhabi and UAE. A recent unpublished survey suggests that in certain age groups midwakh use is perhaps higher than cigarettes. It is legal, inexpensive (much cheaper than cigarettes), highly addictive and has high nicotine content-- up to 5 times more than in a normal cigarette. It is easy to make at home and has social sanction and just one or two puffs at a time are enough. It is becoming a major health problem in UAE, especially in the youth, with reported cases of seizures and increased risk of mycocardial infarction associated with it."

Dr Razzak shared that it is not uncommon to see in his clinic heavy smokers of midwakh who are barely 12-13 years of age. In fact, his youngest midwakh smoking patient was 11 years old and had been smoking since age of 6 years. “My patients who switch from midwakh to cigarettes say that they have to smoke 5 cigarettes in a row to get the same effect as that of a single midwakh puff”.

"While shisha smoking is an elaborate process," explained Dr Razzak, "midwakh is far more user friendly. There is no need to have midwakh bars. It can be used in the aeroplane, at home, anywhere. There is not much smoke and very little smell, so it goes unnoticed. It is common for school children to take a puff before going to class, when they feel the craving they just leave the class, go to the washroom and take a puff and come back."

"Midwakh smoking is no longer a problem of just the Middle East and is rapidly spreading to foreign lands. Many of the current websites that sell midwakh are based in the UK and USA and on one such website 238 retailers are listed across USA selling this product”.

One wonders if the tobacco industry is behind its calculated promotion.

But midwakh has not received the kind of immediate global attention it deserves. "There is lack of scientific data on its use. More studies need to be done to evaluate its potential public health threat and make necessary policy interventions before it gets too late to curb its dangerous growth" said Professor (Dr) Rishi Sethi from Department of Cardiology, King George's Medical University (KGMU).

Water pipe smoking

Water pipe that goes by various names like hookah, shisha and narghile,  comes in a variety of designs but essentially the tobacco smoke passes through a water bowl before it reaches the mouth of the smoker via a hose. It uses sweetened and flavoured tobacco products. "It smells good, perhaps tricking the brain even more" say experts.

And yet, as speaker after speaker confirmed at the 16th WCTOH, water pipe smoke delivers to the body  toxicants that can be equal or worse than those in cigarette smoke. Findings indicate that carbon-mono-oxide (CO) content in it is much more, while nicotine is similar to that in cigarette smoke. A single water pipe session can expose the user to 1.7 times the nicotine delivered by a single cigarette. There are long term effects too and a wide range of diseases have been associated with water pipe smoke but more research and evidence base is needed.

It is indeed heartening to note that Sharjah has taken the lead in recently banning use of water pipes in public places.

Gemma Vestal, Technical Officer, WHO's Tobacco Free Initiative (TFI), said that water pipe smoking is increasing globally, especially among school and university students. While it was traditionally associated with older men in the Middle East and Asia, during the last few years there has been a surge in its use, especially among the youth, in other regions as well.

Water pipe smoking is present in all six regions of the Middle East. Water pipe smoking prevalence has been found to be higher than cigarette smoking in all 17 countries of the eastern Mediterranean region in youth aged 13-15 years.

As per Global Youth Tobacco Survey (GYTS) 2009, in Jordan, use of water pipe smoking in adolescents 13-15 years of age was 27% in males and 16% in females; 44% of them getting access to it at home and 15% in coffee shops. One study showed a 40% increase in water pipe smoking in 7th grade students in Jordan between 2008 and 2010.

HRH Princess Dina Mired, Director General, King Hussein Cancer Foundation, Jordan rued that ‘Shisha curse has invaded our shores during the past 2-3 years and it is worse than cigarettes. Shisha sessions as are culturally acceptable where the entire family may gather together to smoke—from kids to grandmothers smoking together for 1-2 hours’.

“In 2012, 319 water pipe smoking companies registered in Jordan, while 40 companies registered for flavouring of shisha. Recently Phillip Morris has acquired 85% of the local companies. So the attack from tobacco industry is massive as they are losing markets in other countries like Europe and USA. I think we have to change the way we communicate with the youth and people about smoking. Arabs love conspiracy theories. So we are now telling the people that the industry is hatching a conspiracy against our health, making our health pawns in their quest for profits. So we need to stop their attack. And perhaps this strategy will work.”

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CNS: citizen-news.org
Jawad Al Lawati, Senior Consultant, Ministry of Health, Oman, lamented that the spread of water pipe smoking cafes/ bars has increased by 38% (from 190 in 2008 to 263 in 2013) in Oman. Shisha is being advertised even under the garb of advertisemnets for shisha assorted flavored condoms.

Tania Cavalcante of Brazil told that even as smoking prevalence decreases, water pipe smoking is becoming increasingly popular among Brazilian youth, fed by the myth that is not harmful. She informed that: “Brazil has a thriving waterpipe market. Brazil’s imports of narguille (the name for water pipes in Brazil) increased from $18800 in 2005 to $125000 in 2007. Many websites advertise its internet sale and there are even YouTube tutorials available on tips for its use by beginners. One can find posters of water pipe smoking targetting women and announcing hookah meetings. However the smoke-free federal legislation from May 2014 has included Narguille in the prohibition. But compliance to this needs to be enhanced in bars/cafes that allow narguille use”.

Water pipe smoking is also gaining grounds in USA college students, and nearly 1 in 5 adolescents will try water pipe smoking before high school graduation. In Canada, while cigarette smoking has significantly decreased in recent years, ever used water pipe smoking significantly increased by 6% between 2006 and 2010. Small scale studies in South Africa focussed on students has found 20% daily users in high school students, and 40% current use of water pipe smoking in university students.

Perhaps immigration of people from the middle east to the west is fuelling water pipe smoking use in the Western world through profileration of shisha/ hookah bars in urban cities—venues that are frequently exempted from smoke-free policies in many countries.


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CNS: citizen-news.org
And let us not forget the e-cigarettes whose market is galloping at an unregulated fast pace. This what Dr Ehsan Latif, Director (Tobacco Control), International Union Against Tuberculosis and Lung Disease (The Union) told Citizen News Service (CNS): “It was perhaps in 2001 when the tobacco industry started using a phrase ‘harm reduction’ as a way to enter into public health policy debate. What they meant by harm reduction was that they said they could produce cigarettes with better filters and low-tar content so that the harm caused by the cigarettes would be lesser. 10-15 years on they are doing the same with electronic cigarettes. There is a huge market for e-cigarettes and they are already more than 450 brands in the market. Industry is positioning e-cigarettes not as a cessation device, rather as a device that will keep them addicted to nicotine. They stop short of saying it is a cessation device, because they do not want people to quit. BAT is calling it as a substitute to cigarettes. Tobacco industry says using e-cigarettes is not smoking but vaping- but when they advertise they say it is smoking! So we can see the treachery there. For me it is a very disturbing situation because e-cigarettes are re-normalizing smoking. This is the right time to be proactive. We cannot allow e-cigarettes to come into our society. Once it becomes a ‘normal thing’ in our society then it will be just so hard to get rid of it”.

No such thing as a 'safe' tobacco product

Thus even as smoking rates subside, tobacco is disguising itself to reappear in different other forms. "But let us not forget that there is no such thing as a safe tobacco product - tobacco use will be as deadly no matter in what form we consume it" cautions Professor (Dr) Rishi Sethi from Department of Cardiology, King George's Medical University (KGMU).

Like cigarettes, alternative forms of tobacco use also need stringent regulatory measures that are adapted to local situations and supplemented by preventive measures within the World Health Organization's Framework Convention on Tobacco Control (FCTC).

The conference theme of ‘Tobacco and Non-Communicable Diseases’ also highlights the fact that tobacco use (in any of its myriad forms) is the most alarming common risk factor for diseases causing millions of deaths every year and contributing to the enormous burden of NCDs all over the world.

Shobha Shukla, Citizen News Service (CNS)
Follow Shobha on Twitter: @shobha1shukla
21 March 2015