The waterpipe: an emerging global epidemic in need of action

The story has been told many times: waterpipe, a centuries-old tobacco use method in which smoke is passed through water before being inhaled, probably originated on the Indian subcontinent and southeast Asia. Over the years, it spread and became popular in the Middle East. During most of the 20th century, it seemed that waterpipe’s heyday had passed, in favour of easy-to-use types of tobacco such as cigarettes. Its use was not even registered in the expanding body of global tobacco surveillance systems. The medical and public health literatures made little note of it: Rakower and Fatal’s examination of lung cancer mortality rates by ethnic groups in Jerusalem that differed in their use of waterpipe, appearing in the British Journal of Cancer, was the first notice of waterpipe in Medline in 1962, and almost 20 years were to pass before any additional studies were to appear. But things suddenly changed in the 1990s: upticks in use were observed in the Middle East, especially among teenagers and young adults. This was mostly fuelled by the invention of flavoured and easier-to-use tobacco, a growing café culture in the Middle East, and expanding internet availability and globalisation. As a result, waterpipe use has snowballed globally at the start of the 21st century. Tobacco Control published the first review of waterpipe’s global spread and health effects in 2004, noting the scant but steadily increasing research base, and the potential for waterpipe to upend successes in global tobacco control. A decade later, that forecast has come true. In this supplement, Maziak et al note that the “global evolution of this smoking habit has exceeded worst predictions.” In several Middle Eastern nations, the waterpipe has quickly replaced cigarettes as the most popular method of tobacco use among youth, and in several other parts of the world, it is becoming second only to cigarettes. Among US high school students, cigarette use has dropped 33% during the last decade, while use of noncigarette combustible tobacco products, including waterpipe, has increased by 123%. In the aftermath of this re-emerging strain in the global tobacco epidemic, there has been an explosion of interest in waterpipe, and several hundred scientific papers about it have now been indexed in PubMed. The seven reviews in this Special Supplement comprehensively document the tremendous progress that has been made during the last decade in understanding waterpipe’s toxicity, epidemiology, addictiveness, health consequences to users and bystanders, and policy implications. Ten years ago, little data were available to challenge the pervasive notion that waterpipe smoking is a relatively safe pastime compared with cigarettes. Such misinformation was propagated by misleading descriptors on waterpipe tobacco packages about its supposedly low tar and nicotine content, absent or weak health warnings, and the belief that whatever harmful constituents waterpipe smoke does contain are ‘filtered’ out by water. Careful work by several groups, however, has dispelled these false claims and misperceptions. Shihadeh et al synthesise now sizeable literatures from analytic and human biomarker studies demonstrating that waterpipe smoke is a substantial inhalation hazard. It is a biologically active respirable submicron aerosol that induces cellular responses leading to chronic obstructive pulmonary disease and arterial disease. Like cigarettes, waterpipe delivers nicotine, carbon monoxide and ‘tar’ to users. From this ‘tar’, 82 toxicants have been quantified in waterpipe tobacco smoke to date, including polyaromatic hydrocarbons, tobacco-specific nitrosamines, carbonyl compounds and volatile organic compounds. Given these similarities in toxicant exposure, it is not surprising that a growing literature indicates that waterpipe smoking is associated with the same extensive laundry list of adverse health effects as cigarette smoking. In the short term, waterpipe smoking increases heart rate and blood pressure, stimulates inflammatory processes and impairs pulmonary function. An additional short-term burden of waterpipe smoke, distinct from cigarettes due to the use of charcoal to heat waterpipe, is the risk of carbon monoxide poisoning. Although high-quality studies on waterpipe’s long-term effects are still scarce, growing evidence indicates that the chronic health effects of waterpipe smoking can mimic those of cigarette smoking, including bronchitis, emphysema, lung, gastric and oesophageal cancers, periodontal disease, obstetrical complications and low birth weight, osteoporosis, obesity and metabolic syndrome, and mental health problems. Articles in this Special Supplement by Aboaziza, Akl, Jawad, Maziak, and their colleagues, 7–9 make it clear that determinants at multiple levels are driving this epidemic. Waterpipe smoke delivers substantial amounts of nicotine. For many users, this exposure may result in dependence, revealed by urges to smoke and other withdrawal symptoms when they abstain, relief of these symptoms when they smoke and difficulty quitting, even when motivated to do so. While these features are remarkably similar to those exhibited by dependent cigarette smokers, waterpipe dependence may have unique associative components (eg, specific sights, sounds and smells, and the highly social and ritualistic nature of its use) and may be marked by the transition from social to solitary use. These differences may be important in preventing and treating its use. Individual-level and interpersonal-level determinants of waterpipe smoking have received the most attention to date. Although use patterns are still evolving, waterpipe use clusters among younger age groups, the educated and males. In the absence of the stigma attached to cigarette smoking by females in traditional Arab societies, its use among girls also has been increasing. In addition, waterpipe use is much more common among cigarette smokers, raising concerns about the ‘collision of two epidemics’ and expanding tobacco-related morbidity and mortality. Fuelled by misperceptions about its health effects and addictive potential, as well as a mass media environment that emphasises a global youth culture, waterpipe use is seen around the world as a socially acceptable, fashionable, relatively harmless and inexpensive way to relax with friends. These determinants have conspired in extremely lax regulatory environments around the globe to escalate waterpipe use. Reviewing tobacco-related legislative documents of 62 countries, Jawad et al show that most do not specifically address waterpipe regulation and, at best, rely on ‘generic’ tobacco definitions to address waterpipe use. Unfortunately, as noted by Correspondence to Kenneth D Ward, University of Memphis School of Public Health, Syrian Center for Tobacco Studies, Memphis, TN 38152, USA;kdward@ memphis.edu