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Measuring Real Exposure to Narghile (Hookah, Shisha) Smoke & Other Concerns Related to Public Health
- Kamal Chaouachi (2 July 2006)
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Kamal Chaouachi, Researcher in Socio-Anthropology and Tobaccology Paris (France)
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Measuring Real Exposure to Narghile (Hookah, Shisha) Smokeand Other Concerns Related to Public Health Below are comments on
the new study published by AUB (American University of Beirut) researchers: Tamim H, Akkary G,
El-Zein A, El-Roueiheb Z, El-Chemaly S. Exposure of pre-school children to
passive cigarette and narghile smoke in Beirut. European Journal of Public
Health 2006 (May 4): 4 pages. KEYPOINTS: 1- Measuring Real Exposure to Narghile
(Hookah, Shisha) Smoke 2- Nature of Narghile Environmental
Smoke 3- Confusion about Smoked Products 4- Does 1 Narghile Equal 100 Cigarettes
or only 1 Cigarette ? 5- Gender Differences 6- Containing Growing Confusion 1- Measuring Real
Exposure to Narghile (Hookah, Shisha) Smoke The aim of the study
was to focus on narghile passive smoking but we are afraid the objective was
missed for obvious methodological reasons. Certainly all the provided figures
are useful for passive cigarette smoking in Beirut and this is because
cigarettes can unfortunately be used in any room of the apartment or house the
parents are living in with their children. This notwithstanding, we must point
out here, for those who do not know the Oriental way of life, that narghile
(hookah, shisha) is generally and preferably smoked outside: on the balcony, in
the garden, on the roof terrace, etc. In these conditions, we are afraid no
conclusion can be drawn from the figures given in the table as they not reflect
the real exposure of children to narghile smoke. We regret that this fact was
glossed over when the questionnaire was designed. We have repeatedly been
warning over the past years against the misuse of questionnaires in surveys
about narghile smoking (1, 2). Indeed, there are similarities and
dissimilarities between cigarette and narghile smoking and these must be
clearly identified (3). Besides, The nature
of smoke is highly different from that produced by cigarettes, particularly
regarding the so-called environmental one at the heart of the a.m. study. This
is because water is very efficient in this respect. As Deckers and her team
rightly note: “One of the only articulated benefits to this tobacco
alternative is the minimal release of sidestream smoke, which would ultimately
place by-standers at risk for ETS exposure” (4). 2-Nature of
Narghile Environmental Smoke Smoke constituents in
the case of the hookah are filtered out in three different ways and to varying
degrees. Firstly, inside the water vessel; secondly during the long run of the
smoke, from the bowl at the top to the nozzle at the end of the long suction
hose, a distance of about two meters on average that may however reach much
longer figures. Thirdly, during the production of smoke itself because the
temperatures are extremely low in comparison with that at the burning tip of a
cigarette. From a chemical point of view, this has great consequences. For
instance, not only there is a “minimal release of sidestream smoke” (4) but
even the mainstream smoke is freed, to a great proportion, from famous
irritants like acrolein, acetaldehyd, formaldehyd, and other elements (5). This
is why the resulting corresponding smoke is felt as “milder” than the harsh one
produced by cigarette, even for non-smokers. Indeed, in our endeavour to
develop a nationwide plan for hookah use prevention in France relying on human
non-machine narghile smoking, we are taking this fact into consideration. This
intelligent approach will allow us to gain credibility among smokers who may
oppose our arguments. We only mentioned irritants but a series of studies,
including unpublished ones, suggests that other dangerous elements are actually
filtered out. In any case, exposure to tobacco smoke is not beneficial for
health although we must keep objective in each of our statements. 3-Confusion about
Smoked Products Tamim et al. state: “In
Lebanon, there has been a revival of narghile smoking over the last decade.
Narghile (also known as water-pipe, shisha, hookah, or hubble bubble) has been
practiced for centuries in the Middle East. The main ingredient of narghile is
the ‘tumbak’, a dark-paste tobacco lit by charcoal embers. The tumbak is piled
on a tray atop a pipe connected to a glass bottle that is half-filled with
water, and a burning charcoal is placed directly on the tumbak (figure 1) […]” 1-We are afraid
tumbak is not a “dark-paste” tobacco. For a detailed and discussed typology of
the different kinds of tobacco and tobacco-based smoking mixtures, please refer
to our previous work which is, indeed, more then a mere ethnographic
classification exercise (2, 5). For having not paid the required attention in
this field, the authors of recent and widely advertised studies, misled by the
“jurâk” misnomer, used by local scientists in Turkey, actually mistook one type
for another (6). In any case, the Middle East revival and the world craze for
hookah smoking is in direct relation with the use of another product: tobamel
(mel is for honey in Latin), the flavoured tobacco-molasses based mixture
(called mu‘assel in Arabic which literally means “honeyed”). It is absolutely
not tumbak which is plain raw tobacco. Presuming that the authors actually
meant tobamel, in which case the description was wrong, it is incorrect to
state that it is burned (5). Finally, by openly
citing (figure 1) the name and the full address of a commercial company selling
narghiles, Tamim and her team failed –by mistake, we hope- to comply with a key
deontological principle of tobacco research. 4-Does 1 Narghile
Equal 100 Cigarettes or only 1 Cigarette ? Tamim et al. state: “A
recent study found that the total particulate matter (TPM) that is inhaled by
narghile smokers is 1.10 g/h. When compared with a range from 1 to 27 mg of TPM
per single cigarette, this hourly inhalation of TPM with narghile would equate
to a mean of five packs per day of cigarettes”. Firstly, the authors
should know that the study they refer to did not deal with tumbak but with
tobamel (7). Secondly, although we do not know where the above figures
precisely come from, we will take them as granted. Interestingly enough, while
all authors of recent studies on narghile focussed on nicotine or tar (the
nicotine free dry particulate matter), Tamim and her colleagues insist on TPM
and on making comparisons with cigarette smoking on this basis. From the outset, let
us say that the referred to study (7) did not at all establish the TPM “inhaled
by narghile smokers” for the very reason that it was based on a smoking machine
set with parameters and under conditions that have no relation with the reality
of the human smoking behaviour, despite the underlying topography and the
integral related calculus done to obtain the final mean figures used as
parameters for setting the smoking machine. We would like to draw the attention
of many researchers, unfamiliar with the Middle East and narghile smoking, to
just one among the many details they may ignore of the complex context. The
charcoal used in the corresponding experiment was of the quick-lighting type,
i.e. not the natural charcoal traditionally used in the Middle East, and still
it is, to a very great extent. Besides, this charcoal was kept in the same
position during almost one entire hour of continuous strain smoke pumping.
Obviously, such a process helped in actually charring the smoking mixture and
eventually allowed the delivery of high
quantities of tar. In any case, as we
recalled recently (8), the most renown specialists, like Kozlowski for
instance, actually warned against the use of smoking machines in the field of
cigarettes, where, however, the smoking session (c. 5 minutes) is extremely
short in comparison with the hookah (30-60 minutes)(9). We also remind that
the use of smoking machines in this field is not so recent as some people
believe. Early famous studies on the chemistry of narghile smoke (10, 11) are
there on the shelves of libraries. If we are to consider TPM as Tamim did,
Hoffmann and his team found that, for 100g of tobacco products: a 85mm plain US
cigarette would yield 6.2g of particulate materials vs. 0.74 for a narghile (a
Syrian one by the way). He also found that in “1.0 g of particulate material
for mainstream smoke of tobacco products”, a 85mm plain US cigarette would
yield 77.4 mg of nicotine vs. 51.4 mg for the narghile. Certainly the world has
changed and cigarettes changed (12) but did the chemical processes also changed
so dramatically with time ? Further to a
comprehensive critical review of the related literature in this field, we
conclude that the study by Rakower and Fatal (10) might be the most objective
and the closest to the real world (for the given product). Unfortunately, here,
we cannot go too much into the details. We just wanted to show that relativism,
at the heart of the anthropology discipline, should also be placed at the
centre of biomedical sciences, shouldn’t it ? Indeed, what is the
point of this global mystification with arithmetic equations like 1
narghile=200, 100, 50, 40, 10, 5, 1, 1/2 cigarette(s) as if we, ignorant
customers, were attending a permanent auction sale of smoking items ? Indeed,
is this a good method to design best prevention practices or the right way to
discredit our work among the growing dozens of millions of users around the
world ? 5-Gender
Differences Tamim et al. state: “The
gender difference in parental cigarette smoking rates in Lebanon (31.6% versus
16.6%) is not as pronounced. Maziak attributes the rate of female smoking in
Syria to conservative social attitudes and a low level of social
liberalization. Accordingly, a higher degree of Westernization in Beirut,
compared to other cities in the Arab world, could also explain the higher rates
of parental female smoking. On the other hand, narghile smoking does not seem
to follow a gendered pattern. Even the rates of narghile smoking among both
sexes are very close: 3.5 times/week for mothers and 3.7 for fathers.” We fear this question
of “social liberalization“ and “westernisation” may reflect orientalist views
even when they are put forward by “Orientals” themselves (13, 14). Contrary to
all expectations and quick analysis, the revival of narghile in the Middle
East, and its craze in the Arab World as a whole, show that shisha smoking is
actually a strategic “liberation” instrument (we are sorry to use the same
phraseology) used by women. Early pre-world craze field based
socio-anthropological work established this unexpected finding (5). A similar
error can be found in the first report on “Waterpipe” smoking ever published by
the World Health Organisation (15). This also happened with a famous newspaper
featuring a supposedly Muslim woman smoking a cigarette, breaking free from
tradition and “asserting” her freedom this way (16). This last example was
found to be extremely shocking for many tobacco control activists in the West
who considered it was a blatant form of glamorising the use of cigarettes,
particularly among non regular smoking populations. As for the so-called
“Westernization in Beirut compared to other cities in the Arab world”, this is
not in agreement with our findings on smoking in the Arab world (5). One
counter-example will be enough in this respect: that of Tunis, a not less
“westernised” city of the Mediterranean where female parental smoking is
substantial though much lower than in the Lebanese capital. There are obviously
other factors at stake. In a global world
that offers only but an extremely negative, gloomy and hostile environment for
new generations, we have to take care with the words we use and not mistake
“westernisation” or “social liberalisation” for true individual freedom. In
Syria, the female adult literacy rate reaches 74% which should be considered as
a good point. Wherever neo-liberal economies of the G8 type prevail, women are
necessarily victims of male exploitation, everywhere in the world and not only
in countries of the so-called “developing world”. Therefore, the direct
relation between cigarette smoking and “social liberalisation is certainly not
a good equation. 6- Containing
Growing Confusion 3 years after the
World Congress on Tobacco (Helsinki, 2003), research on the hoookah is reaching
unexpected levels of global confusion. Tumbak is taken for tobamel
(mu‘assel)(17), jurâk for tobamel (6), a smoking machine for a narghile user
(7), female users for prisoners of tradition, etc. Perhaps 30 or 40 new studies were published
over the past three years and we are afraid the best work in this field still
remains that of researchers from the South as we emphasized most recently (8). Arabs would call
“fawda” this kind of situation and God knows the heavy meaning of this word in
their language. A famous, and very often cited though erroneous, paper, largely
infused the idea that shisha smoking was keeping its users, in the Arab world,
far away from reality (18). Now, In view of the growing confusion, certainly
there would be some truth in adapting and rewording it title by putting: Narghile
Smoking Keeps Researchers in Wonderland… Given this situation,
what can we do to help our colleagues in rationally considering the objective
facts related to the growing epidemic ? Indeed, for how long again will
researchers be repeating, as in this new study by Tamim et al., that more
research is needed to establish the “determinants” of narghile smoking ?
Certainly, the scenario proposed for Syria, a country with a similar narghile
smoking profile as Lebanon, missed the point (8, 19). However, how many more
studies will we need in order to begin to be able to understand what is
happening in the street ? The answer to this huge question, elaborated over
several years of research, is there and was published a long time ago (5). Most
recently, we clearly set out, both in the Courrier des Addictions, a
research journal supported by the Francophone Society of Addictology, and in the first issue of Tabaccologia,
the guidelines and principles for any work in this field (1, 2). We do refer to
publications in French and Italian journals –with English abstracts- as we are
commenting on a paper of the European Journal of Public Health.
Moreover, it is clear that many researchers in a francophone country like
Lebanon can read French, can’t they? Has not the time come
to serenely work and reflect on narghile (hookah, shisha) smoking? Has not the
time come for our colleagues and officials in charge of public health,
apparently very concerned by the new world “epidemic”, to sit at a table and
share with us the Middle East Peace Pipe and pay attention to what we have been
saying for years now (8) in highly relevant publications (1, 2, 5, 20) ? For
instance, the “new” quantitative findings that “narghile smoking follows
different gender and social patterns than cigarette smoking” (17) are actually
supported by previous qualitative work carried on 10 years ago (21). If, in the
future, Tamim and hers colleagues envisage to lead more studies on this
sensitive and complex field, we strongly invite them to participate in the
novel cooperation project we are launching for researchers in this field (8). Kamal Chaouachi
(kamcha[A]gmail.com) Researcher in Socio-Anthropology and Tobaccology Consultant in Tobacco Control (Paris) REFERENCES (1) CHAOUACHI Kamal. Shisha,
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narguilé. Anthropologie d’un mode d’usage de drogues douces [Eng.: An
Anthropology of Narghile: its Use and Soft Drugs], Paris, L'Harmattan, 262 pages. Conflict of Interest:None declared |
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