Strategic Brief Waterpipe Tobacco Use

Transcription

1 August 25, 2011 In Alberta, waterpipe use is increasing, especially among youth and young adults. Several factors may be contributing to this increase: 1. greater waterpipe availability and more marketing 2. introduction of a wider variety of flavoured tobacco into the market 3. experiencing the exotic oriental ambiance of waterpipe smoking 4. teens and young adults curiosity and propensity to try new things 5. the social aspects of waterpipe smoking 6. the common belief that using a waterpipe is less harmful 7. waterpipe smoke doesn t smell or taste like that from a cigarette 8. waterpipe (Shisha) cafés exemption from clear air legislations 9. waterpipe products are not as regulated as other tobacco products Waterpipes, which are also known as hookah, narghile and shisha, come in different shapes and sizes; however, they have a similar design, are used in the same way and share the defining feature of smoke passing through water before inhalation. 1 Products smoked in waterpipe are marketed and labeled as 0.0% tar and 0.5% nicotine, 0.0% tar and 0.05% nicotine or 100% tobacco and nicotine free (the so called herbal products); however, these marketing and labeling claims are not accurate. 2 For instance, in California, a laboratory test conducted on waterpipe smoking mixtures marketed as tobacco free found that the products did contain tobacco. 3 The most popular product available is Muas sel (an Arabic word meaning honeyed ). Muas sel is a mixture of tobacco leaves, glycerin and/or honey that is flavoured with apple, mint, strawberry or other fruits. 4 The average amount smoked in a session (20 grams of regular Muas sel) contains 67 milligrams of nicotine. 5 Charcoal is used to heat the tobacco, and about 5 grams of charcoal are consumed in a smoking session. The temperature of tobacco burning in a waterpipe ranges from 450 C closest to the charcoal to 50 C at the head outlet, 6 which is lower than the maximum temperatures of 900 C for cigarettes. 7 This lower temperature results in incomplete combustion, which suggests that the smoke production and composition will not be the same as for complete combustion. 8,9 Whether the products contain tobacco or not, combustion of any matter and the resulting smoke will create air pollution and, potentially, will have negative effects on health. Investigators in a trial comparing waterpipe smoke using tobacco products or non tobacco products found no difference between the two products in carbon monoxide (CO) exposure levels and concluded that the health risk of smoking non tobacco products using a waterpipe could be similar to those of smoking tobacco as long as charcoal is the heat source. 10 Waterpipe smoking is not a safe alternative to smoking cigarettes and can potentially cause serious health effects for those exposed to the smoke. 11,4 It is widely believed that the water in the waterpipes filters the smoke, eliminates most of the chemicals resulting from the tobacco burning process and reduces the harmful effects of smoking. This belief is encouraged by the fact that the smoke doesn t smell like that from a cigarette and is significantly cooled as it passes through the water and the long delivery pipe, which reduces its harshness. However, empirical studies do not support this belief and indicate that the waterpipe smokers are actually at risk of exposure to high volumes of smoke, 12 which contain high levels of toxicants and carcinogens such as arsenic, beryllium, nickel, cobalt, chromium, lead, 8 CO, 13 particulate matter, 14 and volatile aldehydes. 15 For more information AlbertaQuits.ca Call toll-free QUIT (7848) 1

2 Compared with cigarettes, waterpipe tobacco smoking is associated with 3.75 times greater carboxyhemoglobin (a form of the oxygen transporting protein hemoglobin that has bound CO and is no longer available to carry oxygen) levels in the bloodstream and 56 times more smoke inhaled; 16 a waterpipe smoker may inhale as much smoke in a one hour session as someone who inhaled 100 or more cigarettes. 9 Waterpipe smoking increases heart rate, systolic and diastolic blood pressure and expired air CO in those who smoke. 17 Tobacco smoke from waterpipes has been linked with diseases that are known to be associated with cigarette use including malignancies, 4,18,19,20 cardiovascular disease, 21,22 lung diseases, 23,24 pregnancy complications, 25 oral or dental complications, 26 hematologic disturbances, 27 genetic abnormalities 28 and infectious diseases. 4 As for cigarettes, waterpipe smoking is a delivery mechanism for highly addictive nicotine. 4 Waterpipe smokers, especially daily smokers, show signs and symptoms of nicotine dependence. Many waterpipe smokers have increased their smoking frequency and intensity over time. 1 Smokers make efforts to ensure that they have access to waterpipes, and use of waterpipes dominates smokers social and recreational activities. 29 Waterpipe smokers have expressed an interest in quitting, have attempted to quit in the past 30 and have reported symptoms similar to those reported by cigarette smokers who are trying to quit. 31 In Canada, waterpipe use was reported by 4% of Canadians aged 15 years and older in 2006; of those, 13% were youth aged years, 25% of them were young adults aged years and the remainder were older adults. Among those who have used waterpipes, 29% thought that smoking tobacco in a waterpipe was less harmful, 34% thought it reduced the level of tar, and 24% thought that smoking tobacco in a waterpipe reduced the health risks compared to smoking cigarettes. 32,33 In the absence of a national strategy to curb this public health threat, it was not surprising to see reports about increased waterpipe smoking prevalence, for instance, in Alberta. The 2008 Alberta Youth Experience Survey showed that about 10% of the students (Grades 7 12) had tried a waterpipe. 34 In 2009, the waterpipe use was more acceptable among Canadian students due to the erroneous view that smoking a waterpipe is less harmful than smoking cigarettes. 35 In 2010, a study in Montreal found that about 23% of youth aged years reported waterpipe use in the previous year. 36 Unpublished preliminary analysis of Canadian data from the 2006 Youth Smoking Survey (YSS) indicated that over 4700 Canadian children in Grade 8 are currently using waterpipes. 37 This number is worrisome given the fact that children and youth cannot hide in a dark street corner and smoke waterpipes as they often do when smoking cigarettes. The question is where these children and young people have access to waterpipes. Unfortunately, this information was not collected by the YSS. Furthermore, the YSS data analysis indicated some correlation between smoking waterpipes and the use of other drugs. For instance, ever had a drink of alcohol was reported by about 94% of those who smoked only waterpipes versus 69% of those who did not use tobacco; similarly, ever used marijuana was reported by 74% versus 26% and ever used hallucinogens was reported by 25% versus 5.7% of these two groups, respectively. This cross use of substances was reported elsewhere suggesting that waterpipe use could be a gateway for other forms of tobacco and drug use 38,39 and could cause relapse for people who have quit smoking cigarettes. 40 2

3 In November 2009, the Royal Canadian Mounted Police (RCMP) seized about two tons of Egyptian shisha tobacco in Oakville, Ontario. 41 Similarly, in2010, the RCMP seized over two tons in Montreal, Quebec, in March 42 and about seven tons in Mississauga, Ontario, in April. 43 The tobacco products seized were not identified as containing tobacco, and the products were not stamped under the requirements of Canada s Excise Act. 44 Charges stemming from these seizures can result in fines of up to a million dollars and in imprisonment for up to five years. The willingness of the importers to risk such penalties and the amounts of tobacco seized could be good indicators of the size of the waterpipe smoking business in Canada. Recently, the Ontario Tobacco Research Unit (OTRU) issued an update entitled Waterpipe smoking: a growing health concern, warning about the health effects of waterpipe tobacco. 45 From public health perspective, allowing a device that can produce about 50 L of smoke which contains constitutions that are still not adequately quantified, in a 45 minute smoking session (compared to 1L of smoke for a cigarette) 12 in a public and enclosed space should not be acceptable practice and, in fact, is likely illegal under the provincial clean air legislations. The increased interest in and knowledge about waterpipe and its health effects led to a ban on waterpipe smoking in public places in some countries, such as Syria; 46 however, the public health response in Canada has been almost absent, 47 and waterpipe smokers enjoy the privilege of smoking waterpipe at waterpipe cafés that still circumvent the clean air legislation in several provinces. 48,49 For years, the interest in smoking waterpipes in Canada and the United States was limited. Therefore, curbing waterpipe use has been more difficult because of the lack of knowledge and understanding of the determinants of waterpipe smoking and the attitude of the general public toward this type of tobacco use. Consequently, this results in a gap in the tobacco control efforts that needs to be addressed without delay. To fill this gap, further efforts are required to increase our knowledge and understanding of the determinants of waterpipe smoking, to translate this knowledge into actions within our communities to increase awareness and to ensure that waterpipe tobacco is sold in accordance with Canadian tobacco laws. Alberta could be a leader in implementing policy measures to reverse the trend of increased waterpipe tobacco use in Alberta, and in Canada. Waterpipe tobacco should be treated as other tobacco products and subject to the same laws that govern and regulate other tobacco products and should be 1. included in Alberta s Tobacco Reduction Act 50 and specifically included in smoke free workplace legislation 51 as well as the Act s retail display ban 2. included in Alberta s Tobacco Tax Act 52 and taxed at rates similar to other tobacco products 3. included in the Government of Canada s Tobacco Act 53 and specifically included in the Act s flavour additive ban as well as subject to the same packaging and labelling requirements of other tobacco products (including mandatory health warnings on packages) 3

4 The primary components of a waterpipe Contemporary waterpipes are handcrafted cultural objects with aesthetic as well as functional properties. The typical narghile forms a sinuous hourglass like figure and has several parts. The base is a vase like chamber made of coloured blown glass that is often adorned with hand painted decorations. The chamber, which is filled partially with water, attaches to a decorative brass or wooden column with a long brass tube (stem) at its core. The bottom of the stem is submerged in the water in the chamber. The rest of the stem rises up through the column and is crowned with a small ceramic bowl and a brass disk for catching ash. Near the middle of the column is a fixture to which a smoking hose (approximately 1 m in length) is attached. Typically, the smoking hose has a wooden grip that forms the mouthpiece and is decorated with fabric and tassels. 1 Tobacco is placed in the head and often covered with perforated aluminum foil; burning charcoal is placed on top of the foil. Inhaling on the end of the hose produces a vacuum in the air filled space of the water bowl, which causes the smoke to pass through the water (producing bubbles and the onomatopoetic moniker for the waterpipe, hubble bubble ), into the exit tube and through the hose to the smoker. Disposable plastic mouthpieces can be added to limit the spread of disease. The size of the waterpipe, number of hoses and other features can differ widely. 40 Acknowledgements The Tobacco Reduction Program thanks Dr. Fadi Hammal for his contribution to writing and revising this document and for permission to use the image of the waterpipe. 4

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