Shisha

Abstract

Hookah has become the most prevalent method of tobacco smoking

nowadays. Originated in the Middle East, it has spread all over the world, with

the number of users growing day by day. Its pungent and pleasant smell,

taste, and innovative way has attracted millions of people from different age

groups in the United States and the world to take to hookah smoking.

Numerous bars and restaurants operate without any restrictions, and the

government chooses to turn a blind eye. This book aims to explore and

educate about the hazardous impacts of hookah smoking on the health of the

smoker and the non-smoker, along with its impact on the environment. It

seeks to draw a comparison between hookah and different forms of tobacco

use, to showcase how harmful this simple device is. It also mentions the

efforts of the Centers for Disease Control and Prevention and the American

Lung Association in trying to curb the usage of Hookah in the United States of

America and everywhere else in the world, in general.

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Chapter 1: The day it hit me

It is always a random day or a random moment when disasters strike. It was

the same for me. One fateful, random night, the cough started. I ignored it, as

any rational human would. But then it became persistent. Like with any

rational human, the weird thoughts became persistent as well. "Why me?" I

kept thinking, and then the regret started when I realized the root of the

problem.

I have always known it was bad. But since when have rational human beings

kept away from "the bad"? The four years of persistent hookah smoking came

back to me. Hookah: my wonderful way out of reality, my escape from a tiring

and exhausting day, became the wonderful reason for my "persistent" tiring

days. My stress reliever became my stress giver.

But what is beyond my understanding is why did I ever smoke a hookah? Was

it the stress? Was it nicotine? Or was it the social pressure of being in a social

group of Hookah smokers? No matter what the reason was, the damage done

has been not easy to recover from.

These surface-level effects might

decrease over time, with proper

treatment. But the hidden and much

more severe effects often take the

shape of diseases like cancer, and

organ failure, later in life.

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What exactly is Hookah?

Hookah, also referred to as Argileh, Narghile, Shisha, and Goza, was

invented ages ago in the Middle East. Now, it is famous and widely used all

over the world. It has become the most prevalent method of smoking tobacco.

The Hookah is a water pipe attached to a pipe, smoke chamber, hose, and

bowl. It operates by sending charcoal-heated air past an especially prepared

tobacco combination (called shisha) and then into a water-filled chamber

bowl. The smoke is subsequently inhaled by the user via a pipe and

mouthpiece.

When the user inhales through the pipe, the smoke is drawn over the flavor

and coal-heated into water (which is filled half to ¾ of the pot to create a

vacuum). This leads to the creation of a vacuum in water when inhaled and

evaporated, which delivers smoke into the mouth along with producing

bubbles.

Due to advanced technology, one can also find electric hookahs, hookah pens

powered by batteries, and steam stones, which are generally more mobile

and can be used on the go. Hookah comes in different sizes and shapes. All

this has further made it easier for youngsters and adults to take to Hookah.

Some even take such mobile hookahs to schools, colleges, events, and

offices.

Hookah use has increased in countries with high immigration rates, such as

the United States, Canada, Germany, and Australia. Despite being lower than

in Middle Eastern countries, the numbers have increased over time. It is more

popular among young people because it is readily available in cafes. One can

find numerous cafes, restaurants, and bars open all night with hookahs.
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People have a general misconception that smoking hookah is healthier than

smoking cigarettes. As a result, most people use hookah due to a lack of

knowledge about it. According to various research, using a hookah is as bad

as smoking cigarettes. Some even reckon it is far worse due to the high

amount of toxins present in it.

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Tobacco risks are widely discussed, and in many countries, tobacco in the

form of cigarettes has been banned; this has, however, increased the

popularity of hookah. According to research, students and young people

believe hookah is less harmful and more socially acceptable than cigarettes.

And they use this form to socialize. Despite hookah bars advertising a lethal

product, youngsters are much more attracted to it due to such bars and

lounges providing a relaxing environment, extra privacy, social interactions,

musical settings, food, alcohol, and much more. Such businesses are

frequently excluded from laws related to smoking and drinking.

Hookah also has positive attributes compared to cigarettes, like social appeal,

physical attractiveness, pleasant smoke, relaxation, and deterrents. With a

wide range of flavors and aromas, people can choose their favorite flavor,

unlike cigarettes. In general, many people quit smoking because of the bad

smell, which also reduces the socializing aspect of smoking. Moreover,

Hookah comes in many different enticing flavors, like mint chocolate,

watermelon, vanilla spice, tropical fruit, strawberry, and much more. Even the

smoke of such hookahs smells appealing, causing even non-drinkers, and

non-smokers to try it and eventually get addicted to it.

Alcohol has also played a role in the rise of hookah and its use. It is easy to

use and some even consider it better than cigarettes. Another appealing

feature of hookah is that it can be shared by multiple people thanks to the use

of multiple pipes. The people who smoke hookah are generally sensation
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seekers, lack premeditation, and either earn better, experience anxiety, lead

stressful lives, or live with hookah users who suffer from depression. There is

also a lack of knowledge among healthcare providers and scientists about

hookah as it is not as widespread as cigarettes.

Chapter 2:Global epidemiology

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The Robert Stempel College of Public Health gave a clear picture of the

global picture of hookah smoking. The trend began in the Middle East

hundreds of years ago, then spread globally at an alarming rate, becoming

the most popular trend among youth. In the 1990s, it was confined to older

men and less practiced.

Why has the situation changed so drastically? What is the reason for hookah

being so famous globally? Is this hookah craze a fad, or something that, like

smoking and drinking, will last forever? Even after e-cigarettes and e-hookahs

took over the globe, hookah parlors are still full. Is tradition or culture

important in the development of hookah culture? Is the migration of people

from different countries an important factor in spreading hookah smoking?

In most Middle Eastern countries, people fast all day and refrain from smoking
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and drinking for a month during Ramadan. So, previously, nicotine users who

practiced Ramadan used water pipes as a nicotine alternative. During the

same time, people would set up tents and camps to fast together. Here began

the culture of sharing pipes, and hookah became an irreplaceable part of daily

life and outings. This then spread to urban areas and was passed along to

travelers and visitors. This spread of hookah culture was then intensified due

to migration. That’s how it started to become prevalent in the Middle Eastern

countries and the whole wide world. But our focus is on global epidemiology;

let's see how hookah spreads in other countries and the factors contributing to

it.

Factors contributing to prevalent hookah usage

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Flavor: The flavored water pipe is generally known as Maassel. The multiple

addicting flavors of Hookah are the major draw. Multiple people prefer hookah

to cigarette smoking because of its flavors and pungent smell. Nicotine might

be the draw for addicts and alcoholics, but flavor plays the most important role

in attracting people to hookah smoking. Tobacco is usually crushed when

added to hookah, which brings out its sour taste, which is not liked by the

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majority of people. It is the various varieties of hookah flavors that appease

people.

Café culture: cafe culture has played a big part in the popularity of hookah.

Along with great food, socialization, music, ambiance, and alcohol, cafes draw

youngsters and adults towards hookah smoking. Dance, music, and the ban

on smoking in such public areas have also resulted in a boom in hookah

culture. Strategically, cafes started popping up around schools, colleges, and

workplaces. That has led to the easy availability of hookah. A similar trend

has been noticed in India regarding the situation of such cafes.

Social media: Global communication and the popularity of documenting

everyday life on social media have also attracted people towards the adoption

of popular trends like hookah smoking. Youth get easily attracted to such new

trends. As a result, hookah manufacturers relied heavily on the internet as

their primary marketing tool, according to a 2004 study on internet-based

searches for water pipes. The largely unregulated internet made the water

pipe famous, attracting people to make them at home. The YouTube videos

found user-generated videos and the cool side of them, and they put them in

a positive light. They also found 100 Instagram pages of hookah and shisha

love and 100 different ways to make cool shisha.

Lack of water pipe-specific policies and regulations: Many regulations

apply to cigarettes, but hookah has taken a back seat in terms of regulations,

and many people believe that water filters out the toxic agents in the hookah.

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But only 3% of toxic agents are filtered. Many countries have strict cigarette

policies, but countries that allow the use of water pipes are exempt from such

regulations. There are issues such as oral diseases spreading through shared

pipes. The first global health treaty was approved by 179 countries worldwide,

the results of which indicated the laws in place do not adequately address

hookah smoking.

Misconceptions regarding Hookah: One of the most common

misconceptions among people is that hookah smoking is more healthy than

smoking cigarettes. People feel that as hookah does not have a sour taste or

an annoying smell, it is healthier and has little to no side effects. Often, people

who are trying to quit smoking or drinking take up the hookah. Moreover,

oftentimes, people trying to quit smoking or combat nicotine addiction switch

to hookah to lower their addiction to nicotine but end up being persistent

users.

Peer pressure and enjoyment: hookahs are easily available in most cafes,

bars, and restaurants, even high-end ones. Most people visiting with their

hookah-smoking friends give it a shot and become frequent users. Another

reason is that people go drinking or smoking to have a good time, and now

hookah has replaced drinking and smoking due to its enticing flavors and

appealing smells.

Global Spread:

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The nations where the data was collected found the trends quite alarming. In

the Middle East, it almost replaced cigarettes among youth. It increased from

9% to 15%. It was found to be 8% for 152 college students in the United

States. The average age of users is quite alarming, with most users aged 13

to 19. Global tobacco surveillance systems were implemented. One critical

component was that it focused more on youth, and after surveys in 100

countries, Arab youth predominated. The percentage of hookah smokers in

Canada increased to 10% and in Australia to 4.8%.

Time trends:

Using the available data, it is difficult to construct a clear picture of time

evolution and how different techniques are used by different people. However,
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the efforts of some surveillance systems aided in determining the changed

dynamics globally. The data from the USA between 2011-2012 showed a

32% increase. Canada's data showed a 6.3% increase in teenagers from

2006 to 2010. Furthermore, between 2008 and 2011, there was a 72%

increase in boys and a 136% increase in girls Jordan, according to the study.

In conclusion, the data showed declining results for cigarettes and increasing

usage of other forms of tobacco, mostly hookah.

For all the reasons mentioned above and as per the study conducted, hookah

usage has become widespread all over the world. Starting in the Middle East,

this trend has spread over the globe. Its easy availability and affordable rate

have further contributed to this widespread trend. Meanwhile, global usage

and time trends can be identified, but it is still difficult to figure out patterns of

hookah use.

Chapter 3: Contents present in Hookah

Hookah users frequently believe that hookah usage is less dangerous than

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smoking cigarettes. However, numerous studies have revealed that hookah

smoke contains similar poisonous and toxic components as cigarette smoke,

such as tar, nicotine, and heavy metals. Hookah is not a safe substitute for

smoking cigarettes. Hookah tobacco is frequently sweetened with substances

like fruit pulp, molasses, or artificial sweeteners, and flavored with coconut or

coffee. Flavorings enhance the smell and taste, thereby making them

especially tempting to teenagers.

The main ingredient in hookah is tobacco. The percentage of tobacco in

hookah may vary. For example, hookah pipes could also be named "Mossel,"

with a mixture of around 30% tobacco and the remaining 70% being a

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concoction of flavorings, glycerol, and sweeteners (e.g., molasses and

honey). It has been previously found that the water-soluble portion of cigarette

smoke represented 38% of the particulate matter. Interestingly, Middle East

researchers have subsequently estimated the overall shisha water-filtration

rate to be 38% and concluded that shisha smoke, with only 142 compounds

detected in a pipe filled with Jurak (a mixture of 15% tobacco leaves and 47%

carbohydrates (glucose)), is far less complex than cigarette smoke. This

figure can be compared with the 4,700 substances identified so far in cigarette

smoke.

The other ingredient is Maassel, a sweetened and flavored water pipe that

has been around since the 1990s. It’s generally produced from the

fermentation of tobacco with molasses, glycerine, and fruit essence,

producing a moist, pliable mixture. Before the mixture, they used raw tobacco

that they crushed, squeezed, mixed with water, and molded, but it was difficult

to smoke due to its harsh nature; however, the introduction of maassel

provided a smooth and aromatic smoke. This is what attracts several young

adults.

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It's a frequent myth about hookah smoking that it rids tobacco of toxins like

nicotine. Water-cooled smoke might be gentle on sensitive lung tissues, but

the danger of smoke remains unaltered. The disease-causing and cancer-

causing compounds found in hookah are not removed. Hookah smoke

contains numerous hazardous compounds and toxins that are present in

cigarette smoke as well. Acrolein, chromium, cobalt, lead, and arsenic are

some of the compounds that are present in high quantity in hookah smoke.

Several hookah brands proclaim to be tar-free, but this is false. Tobacco does

not contain tar unless it is burned or heated, and tobacco burning is integral to

smoking hookah. This distinction causes some to conclude that hookah tar is

less hazardous than cigarette tar. However, it is far from the truth.

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Furthermore, the charcoal used to burn the tobacco in the hookah contains

carbon monoxide and other disease-causing toxic chemicals that increase the

danger to hookah smokers.

Comparison with Cigarettes:

On average, a single cigarette contains about 7 to 22 mg of nicotine. A

smoker might absorb an average of 1 mg from smoking a cigarette. On

average, a normal hookah bowl has over the same amount of nicotine present

in over 20 packs of cigarettes. Nicotine is addictive, and smoking a hookah is

no less addictive than smoking cigarettes.

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Moreover, while smoking a cigarette, an average smoker might inhale about

500 to 600 ml of toxic smoke. But, a normal session of hookah smoking will

have an average smoker inhaling about 90,000 ml of smoke. A person

smoking hookah inhales about nine times the amount of CO (carbon

monoxide) as well as 1.7 times more nicotine, in comparison to someone

smoking a single cigarette.

Additionally, inhaling or taking a drag from the hookah requires a stronger

inhalation, so anyone smoking a hookah might be inhaling more toxins and

chemicals.

Hookah Addiction:

Smoking a hookah provides nicotine in the very same way as cigarettes and

other tobacco substances do. Nicotine is extremely intoxicating and has many

negative health impacts. Nicotine enters the brain in about as quickly as 8

seconds. This is then carried by the blood to the adrenal glands, where it

stimulates the creation of adrenaline. It is a hormone that aids in the fight-or-

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flight body's reaction to danger. It produces physiological alterations such as

an irregular heartbeat, a rapid breathing rate, and high blood pressure.

Moreover, nicotine makes one wide awake and decreases the feelings of

hunger and fatigue. This alertness induced by nicotine makes one experience

a sense of euphoria for a short period of time. Furthermore, not smoking

hookah can cause brain confusion, high amounts of anxiety, panic attacks,

excess fatigue, and much more.

Since inhaling from a hookah contains far more nicotine compared to smoking

a cigarette, it's indeed easy to become hooked only after a few puffs. These

products might make one feel elated for a short while, but they may make one

vulnerable to such body conditions and chronic health conditions in the long

run. It can also cause clogged heart arteries and respiratory diseases.

People typically attribute their habit to the social character of hookah smoking

instead of the compulsive elements of nicotine since it happens in group

settings like hookah lounges.

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Chapter 4: Health Effects of Hookah Smoking

Hookah smoking has triple the health effects compared to cigarette smoking,

generally caused by tobacco smoke, charcoal smoke, and oral diseases

caused by sharing the mouthpiece. A recent animal study by Ziad et al.

revealed a positive correlation between P53 mutations in oral squamous cell

cancer, pre-malignant lesions, and normal oral mucosa. Another study shows

effects on baccalaureate mucosa with the help of the baccalaureate

micronucleus cytome test. The water-smoking users showed DNA damage;

there were cell cycle abnormalities, indicating cell death, cytokinesis failure,

genome instability, and the early stages of tumorigenesis. There was a trace

of heavy metals in WTS participants, like lead, compared to cigarette smoke.

Other studies showed seven kinds of carcinogens, 39 CNS depressants (ex:

toluene and benzonitrile), and 31 respiratory irritants. This is generally due to

the limited restrictions on making the coal and flavors, which leads to high

levels of heavy metals in charcoal. CNS depressants are the cause of

headaches, dizziness, and nausea after a long hookah session. The common

effect of hookah is COPD, which increases oxidative stress markers and

inflammation in murine lungs. The inflammatory markers in mice showed an

increase in inflammatory cells, including neutrophils, macrophages, and

lymphocytes. These cells play an important role in lung diseases.

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 Oral Health

The inflammatory response results in several health effects on the oral cavity.

The most common conditions are candida infections, periodontal diseases,

dry sockets, premalignant lesions, and oral cavity cancer. According to five

studies, compared to non-smokers, there is an increased prevalence of

periodontal disease. A separate study shows an association with dry pocket

or alveolar osteitis, which leads to exposing underlying bones and nerves and

causing pain. Another case study showed a statistically higher level of crestal

bone loss and peri-implant soft tissue inflammatory parameters in WTS

smokers. Using a hookah pipe from one smoker's mouth to another's may

increase the risk of infection from transitional diseases such as cancer,

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tuberculosis, and hepatitis. Moreover, researchers have found that hookah

smoking for a period of 30 minutes could lead to high blood pressure, an

increased heartbeat, decreased lung functions, reduced blood oxygenation,

fainting, and brain damage.

 Pulmonary Function:

A case-control study evaluated the association of WTS with airway hyper-

responsiveness using the branch provocation challenge with mannitol.

Interestingly, it showed the same effect as cigarette smoking. When

compared to nonsmokers, even mild use causes lower diffusion capacity,

abnormal epithelial lining, a higher fluid metabolize profile, and increased

proportions of small airway epithelial ciliated cells in young adults. This also

caused the inflammatory changes of an increase in total white blood cell

count, platelet activation, and increased expression of pro-inflammatory

cytokines like IL-6 and TNF-alpha in the bronchoalveolar lavage fluid. The

habit may also lead to COPD, bronchitis, and lung cancer. The physiological

effects on lung function show a decrease in vital capacity, sub-maximal

aerobic capacity, chronic airflow limitation, and total lung capacity. In

everyday users, it causes breathlessness, coughing, bronchitis, nocturnal

coughing, and wheezing.

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 Cardiovascular Effects:

The cardiovascular changes are alarming even with small sections and are

consistent with nicotinic-induced beta-adrenergic activation leading to

sympathomimetic effects. It exhibits effects such as venous outflow, an

increase in heart rate, and oxygen consumption, resulting in an increased CO

blood level and a decreased oxygen blood level after 30 minutes of smoking.

Researchers discovered that people who had ischemic heart disease, heart

failure, hypertension, hyperlipidemia, hyperglycemia, obesity, elevated

fibrinogen, and other conditions that increased their risk of myocardial

infarction (myocardial ischemia) were more likely to die. This demonstrates

that it has the same effects as cigarette smoking.

 Gastro-esophageal Effects:

A study evaluating the association between hookah tobacco smoking and

GERD found that among people not using medications against reflux

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symptoms, there was an association between hookah smoking and severe

and frequent GERD.

 Pregnancy Effects:

Children of hookah users have a lower birth weight, according to studies.

According to research, hookah usage during pregnancy has been related to

asthma in children and an increased chance of developing respiratory

difficulties. Infants born to mothers who smoked hookah regularly during

pregnancy weighed less at birth compared to infants born to nonsmokers.

Prenatal exposure to shisha causes airway inflammation in adult offspring in

the mouse model. The history of tobacco has been the reason for

anthropometric measurements such as length, weight, and head

circumference in retrospective cross-model analysis. Surprisingly, hookah

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smokers had worse anthropometric measures than cigarette smokers. There

are greater side effects in women, such as an increased chance of

menstruation pause and bone loss.

 Risk of Cancer:

In case-control studies, studies of good quality revealed an association

between hookah smoking and lung and esophageal cancer compared to non-

smokers. In a study with a history of hookah smoking for more than 5 years,

abnormal mutant activity was shown. The positive areas in these studies were

mainly in the basal and parabasal layers of the evaluated normal and

premalignant tissue, though they were also positively scattered in malignant

mucosa.

Tobacco smoke contains over 4,800 distinct compounds and over 69 of which

are recognized carcinogens. Furthermore, smoking shisha may impair one's

body's capacity to combat certain cancers. A Saudi Arabian study revealed

shisha users had decreased antioxidant levels and vitamin C compared to

non-smokers. These beneficial nutrients can potentially aid in the prevention

of cancer. Numerous similar research found that the use of tobacco and

hookah leads to malignancies of the mouth, esophagus, pancreas, bladder,

and prostate cancers and tumors.

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Chapter 5: Carbon Monoxide Toxicity

Hookah smoking, like smoking cigarettes, releases several toxicants,

including nicotine, carbon monoxide, polyaromatic hydrocarbons, volatile

aldehydes, and tobacco-specific nitrosamines. One single session of 30–60

minutes of hookah smoking causes 40 litres of smoke, compared to 1 litre or

less of smoke in one cigarette. Similarly, a single session of hookah produces

242-2350 mg of tar and 5.7–367 mg of CO, as compared to 1–27 mg of tar

and 14–23 mg of CO from a single cigarette. CO exposure is very serious and

fatal sometimes, and it is difficult to diagnose because the pulse oximetry is

falsely normal. The long term exposure may cause memory loss, movement

disorders, affective disorders, and personality changes. In young adults,

smoking may result in lifetime morbidity due to continued smoking.

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Carbon monoxide (CO) poisoning is known as the most common fatal

inhalation of an intoxicating gas. It is odourless and colourless. It binds to

several heme proteins, such as hemoglobin (Hgb) and myoglobin, in the heart

and skeletal muscles. Compared to oxygen, CO has a 300-fold higher affinity

to bind Hgb, which eventually affects the oxygen delivery to body tissues,

leading to tissue hypoxia despite the normal PaO2 on arterial blood gases,

the measure of the dissolved O2, and the normal O2 saturation (SpO2), which

is usually calculated from the PaO2 by the regular bedside pulse oximeter.
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Patients who were exposed to CO are usually asymptomatic until

carboxyhemoglobin (COHb) values in the blood reach 10% in smokers and

2% in nonsmokers.

The symptoms of CO intoxication vary in severity, starting with something as

simple as a diffuse headache and progressing to loss of consciousness.

Symptoms mimicking stroke and myocardial infarction might be present. In

severe cases, both cardiac and neurological manifestations can occur. The

duration of smoking, volume of nicotine smoked per puff, and temperature at

which the nicotine is being burned all play a role in why hookah smoking has

around 10 times the amount of CO combusted compared to a single regular

cigarette. Five minutes of hookah smoking produces four times the CO of an

entire cigarette.

When measured among hookah smokers in a field study, an average of 38.5

parts per million (ppm) of CO was present, with an increase of 300% in CO for

their samples, comparing pre- and post-hookah sessions. Furthermore,

regarding nicotine, studies have shown that the peak nicotine concentrations

between hookah and cigarettes were equal, but the longer duration (45

minutes) of hookah smoking resulted in increased exposure to nicotine which

was almost double the dose of exposure. There is more CO than nicotine in

hookah, an approximation of 50 to 1 in comparison to 16 to 1 in cigarettes;

therefore, a hookah smoker would be exposed to a higher CO concentration

in order to get nicotine satisfaction. According to the Undersea and

Hyperbaric Medical Society, generally in cases where COHb is greater than

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25%, hyperbaric oxygen (HBO) therapy is the recommended treatment in the

acute setting, despite the controversy regarding its role in preventing delayed

neurological sequelae. However, due to physiologic restraints in pregnant

patients and children, the lower threshold of COHb levels, 15%, is the cutoff

for HBO therapy consideration. Otherwise, and in the absence of cardiac

ischemia or significant neurologic dysfunction, normobaric oxygen therapy, in

the form of high-flow O2 administered via a non-rebreather mask, is the

mainstay of treatment.

Traditionally, hookah has been lit with natural charcoal, meaning the charcoal

came from the embers of a wood fire. With hookah’s increase in popularity,

many different types of charcoal have emerged. To name a few, there are

now quick light disks, coconut cubes, briquettes, and sticks—all claiming to be

natural. These charcoals are made by using a wood source (trees, coconuts,

dried cane, scrap lumber, etc.) and, in many cases, a casing agent such as

unrefined molasses from sugar cane or starch from flour or corn. The effect

on the smoker is then a combination of all the contributions to the smoke from

various hookah equipment chambers, the individual manner of smoking,

including length of time and puff intensity, the tobacco formulation, and the

charcoal.

The elemental composition and concentrations reflect the origin and

manufacturing process of the charcoal. Charcoal from renewable sources

such as coconut husks and wood embers is expected to have a different

elemental profile than lump charcoal. The man-made charcoals are made

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from a variety of sources and then modified with an agent that aids in caking

and, in many cases, an infused ignition source (quick light types). The total

elemental profile for sixteen charcoal samples and two certified reference

materials was obtained as an initial step in understanding how the charcoal

matrix contributes to first- and second-hand smoke.

The presence and concentrations of toxic metals and organic substances in

charcoal are highly dependent on the origin and type of wood used as the

growth medium (typically soil), the post-harvest treatment of the wood, and

different production processes. Toxic substances are introduced into the

environment through natural (trees) and anthropogenic (treated lumber)

means. The wood and fruit (such as coconuts) are then processed and

formulated into charcoal. Additionally, during the manufacturing process,

chemicals may be added to aid in lighting or encasing the charcoal. The

variations in the charcoals’ origins and manufacturing processes ultimately

affect the types of toxic elements and organic compounds, as well as their

concentrations, to which a hookah smoker is exposed.

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When the smouldering charcoal ignites the hookah tobacco formulation (more

of a charring), the smoker is exposed to putatively hazardous metals and

organics from both sources. The degree of exposure greatly depends on the

charcoal type, the metal volatility, and the length of exposure. The combined

toxic exposure from charcoal and the tobacco formulations associated with

hookah consumption has yet to be studied in detail and is important as a first

step towards understanding the hazardous risks the consumer is subjected to

while smoking hookah tobacco.

The hookah is a multi-component apparatus used for consumption of the

smoke from a tobacco matrix (consisting of wet leaf tobacco and up to 50%

other ingredients). The tobacco matrix is lit using smouldering charcoal, and

the smoke is drawn down the hookah apparatus, through water in the bowl,
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and out the hose to the consumer. Certain studies indicate that hookah

tobacco formulation contains potentially toxic elements such as As, Cd, and

Pb11. With charcoal in the smoking routine, the consumer is exposed to a

second source that may contain potentially toxic elements in addition to those

in the tobacco matrix. The charcoal component of this double jeopardy

paradigm was investigated to ascertain the extent of toxic metals the

consumer may be exposed to resulting solely from the charcoal.

The results show a large degree of variation between samples, with the quick-

lit samples being the most contaminated with toxic metals. This is not a

surprising result, as the origin of the samples will determine the exposure to

high concentrations of heavy metals in the form of paints, preservative

preparations, and soil. The analysis of combusted charcoal samples revealed

that Fe, Cd, and Pb are the only elements lost during the ashing process, as

their content is lower in the ash than in the unburned material.

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Chapter 6: Heavy Metal Poisoning

Heavy metal is defined as having a specific weight of 5 g/cm3, and it is

generally required to perform some actions in our body for metabolism,

growth, and reproduction. However, they are generally toxic when present at

higher levels.

They can enter the body through different sources—the skin, digestive

system, and respiratory system. They can disrupt the metabolic process in

body cells. They can be removed by chemical and physical treatments, which

can enter through food, the environment, and diseases such as cancer.

Heavy metals in the human body could come from different sources and

cause a lot of issues, especially their accumulation effects. Smoking hookah

could be a serious source of heavy metals impacting human health.

Experts confirmed that the hookah risk is concentrated through the hookah

pipe, which when placed in the mouth contains more than 30 known

chemicals such as 3-bromooctane, benzaldehyde, zinc, cadmium, 1-

methylcycloheptene, etc. These chemicals are linked to DNA and thus cause

cancer and many genetic mutations. For example, one of the issues with

smoking hookah is that it contains toxins in the nicotine, which is not filtered

with water.

The flavour can be the main reason for heavy metal poisoning. A study was

conducted at the Department of Environment at the Faculty of Science

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(University of Kufa, Al-Najaf, Iraq) and Al-Sadr Teaching Hospital laboratories.

This study was designed to measure the heavy metal concentrations (lead,

cadmium, and iron) in smokers' blood in Najaf Province and compare those

concentrations with nonsmokers' blood.

These are the results of the above-mentioned study:

When smoking effects can be examined by increasing heavy metal levels

(e.g., cadmium), In the study, cadmium, lead, and iron levels showed a trend

toward increasing among smokers compared to non-smokers. Although there

were some marginally significant effects of smoking, all of these elements

were not significantly impacted by the effects of smoking. For example, the

higher rates of cadmium in smokers' blood were 0.18 ppm compared to 0.02

ppm in non-smokers (p-value = 0.07, T-test = 1.8, Figure 5). Other studies

found that smoking's effects on cadmium concentrations are only important in

young smokers compared to non-smokers. In the results, an increase in

heavy metal levels in smokers' blood (e.g., cadmium) might come from the

nicotine itself, which could directly impact the results. It was highly

recommended that further studies consider diet, nicotine type, and

concentration, which are all factors smokers use. This was also

recommended in a previous study.

Lead concentrations in smokers' blood were higher (0.236 ppm) than in non-

smokers' (0.235 ppm) (p-value = 0.97, t-test = 0.03). This increase in lead

levels was not significant. This study disagreed with previous studies.

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Variabilities in the sample might cause this disagreement with previous

studies. For example, the type of nicotine used from person to person as well

as the duration of smoking per day might have a highly significant effect on

the result.

The results showed an increase in the level of iron in smokers' blood

compared to non-smokers, at 2.25 ppm compared to 1.52 ppm, respectively.

However, this increase was not significant in smokers' blood compared to

nonsmokers (p-value = 0.3, t-test = 1.04). Again, the study disagreed with

previous studies. An increase in the blood iron level could be expected as a

result of a deficiency of oxygen and an increase in hemoglobin to balance this

deficiency, both of which result from smoking's effects. Surprisingly, this

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disagreement in the result with previous studies could come from factors that

need to be considered in future studies, especially dietary systems and

inheritable status.

The smoking duration effect on cadmium, lead, and iron levels were not

significant in the study conducted. A previous study showed that the duration

of smoking significantly affects heavy metal levels. It was found that cadmium

was at 0.26 ppm in people who had smoked for more than 5 years (> 5), while

the lowest value was found in people who had smoked for 1-4 years (0.010

ppm). (P-value = 0.12, T-test = -1.58, Fig. 8). Lead concentrations also

showed an increasing rate during the period (> 5 years), 0.24 ppm, but it was

not significant (p-value = 0.84, T-test = -0.2). Iron was recorded during the

period (1-4) years; the highest values were 3.16 ppm, but the duration was

significant (p-value = 0.02; t-test = 2.48). It was also detected that

concentrations of cadmium, lead, and iron in the smokers' blood was directly

related to their age. For example, an age range of 18 to 30 years was found to

have the highest values of cadmium, lead, and iron (0.194, 0.249, and 2.97

ppm, respectively) (p-value = 0.7, t-test = -0.36, p-value = 0.8, t-test = -0.27,

p-value = 0.05, t-test = -1.97). However, non-significant effects were found in

cadmium and lead but significant in iron in this study. This difference in the

mean of people smoking for longer (> 5 years) compared to shorter (1-4

years) as well as the age differences of smokers was not significant and might

be related to sample variations.

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Chapter 7: Comparison between Hookah versus other

Tobacco Sources

Tobacco has remained famous for centuries, and its usage is rising despite

apparent health risks. Many studies in various regions have highlighted the

potential negative consequences of its usage on nearly all living organisms, in

whichever manner it is used. Tobacco is produced from the leaves of the

species Nicotiana, a night-shade plant native to both North and South

America.

People who practise medicine began to use tobacco in varying ways to treat

numerous ailments. Tobacco is now utilized in a variety of ways in various

regions of the world. Tobacco is cultivated in multiple regions as a commercial

crop for agriculture and administrative treasuries (tax, levies, etc.), and also

for self-consumption.

Ever since its emergence in the South Asian region, tobacco is consumed and

used in various manners and forms. Usage and form differ from region to

region, for instance, people in India, Pakistan, and Bangladesh consume

tobacco with betel leaf, commonly referred to as pan. It is consumed in

cigarettes, bidees (rolled tobacco), clay pipes called chillam, and many more.

Moreover, it is consumed as a chewable in naswar (powdered tobacco),

gutkha, etc.
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Each consumption method has different implications for health. Here is a

comparison between tobacco consumption through various sources and

methods and hookah.

 Vapes:

The method of heating and aerosolizing a fluid (commonly referred to as

"vape liquid") for inhalation is known as vaping. Nicotine or

Tetrahydrocannabinol, the active ingredients present in tobacco and

marijuana, is found in vape liquid. When the vapour in the vape forms, it

condenses into an aerosol. Aerosol contains toxins and tiny particles which

can irritate the respiratory system. Hookahs are not similar to vapes.

The initial and most noticeable distinction is that e-cigarettes contain no

tobacco, although certain cartridges contain tobacco leaves and nicotine.

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While shisha isn't the same as regular tobacco, it's still tobacco. As a result, it

preserves the burning of tobacco, which is not found in a vape.

People using vapes and hookahs are putting their health at risk. Hookahs

present dangers that vaping devices do not. Hookah fumes include at least 82

poisonous toxic agents and dangerous substances, such as tar, heavy

metals, and nicotine. While hookah is the more dangerous of the two,

smokers of vaping products and hookahs are much more likely to develop

inflammatory reactions and forms of cancer of the mouth, sinuses, and throat.

 Pipe Tobacco:

Despite the dangers associated with pipe tobacco, having smoked tobacco

through a pipe is a global practice for ages. Pipes have been traditionally
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used for ceremonial purposes, but the practice has gradually gained

conventional popularity throughout the years.

Pipe tobacco smoking is a type of loose-leaf tobacco. It is burned-dried, which

means that the dried leaves are gradually smoked over a smouldering solid

wood fire in a barn or framework.

This process may take several days to several weeks, with the ultimate

outcome being tobacco that has low sugar but also has high nicotine content.

Nowadays, many pipe tobaccos are aromatic, meaning it has had a flavouring

mixed with them that provides them with richness and depth in smell and

flavour.

While pipe tobacco and hookah are very different, they are both hazardous to

health. Pipe tobacco does contain high amounts of nicotine, but hookah, on

the other hand, contains numerous other added toxins and substances. These

added substances, along with nicotine, make smoking hookah a more

hazardous practice. Pipe smoking increases the chances of cancer,

respiratory diseases, and heart failure, but these risks are lower compared to

the risks associated with smoking hookah.

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 Cigars:

Rolled tobacco leaves filled with tobacco are known as cigars. Because of

how cigars are created, cigar smoke tastes different than cigarette or hookah

smoke and is frequently more unpleasant, causing numerous users to resist

inhaling the cigar smoke. Whether a cigar smoker inhales or not, he remains

at an increased risk of severe health issues. Several cigars contain quite as

much nicotine as numerous cigarettes, making it more dangerous than

smoking a cigarette. There has not been much comprehensive research done

on the comparison of health risks caused by cigars and hookahs. But one

thing is certain, both cigars and hookahs have higher health risks compared to

cigarettes. Both hookah users and cigar users face similar threats and an

increased chance of getting lung diseases, strokes, pulmonary diseases,

tumours, and much more.

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 Oral consumption of Tobacco:

Many people believe that consuming tobacco products orally is more secure

than smoking. That being said, oral consumption of tobacco products can be

equally compulsive and thus is linked to several negative health

consequences.

Because oral consumption of tobacco contains more nicotine than cigarette

smoking, a person who consumes it 8-10 times each day could have the

identical dose of nicotine in one‘s body as someone who smokes cigarettes

30-40 cigarettes products per day.

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As per this calculation, oral consumption of tobacco can lead to severe health

conditions compared to hookah smoking. It can cause dental problems, mouth

cancers, blood pressure, heart diseases, and diabetes.

Smoking hookah leads to several hazardous disorders and conditions.

Tobacco, in whichever form it is consumed, remains lethal and poisonous.

While cigars, oral tobacco consumption, pipe smoking, vapes, etc. all have

detrimental effects on the human body, but hookah remains the most

hazardous of all. There is a significant lack of studies conducted related to

which method of tobacco consumption is the worse. However, certain

comparison studies show that hookah smoking poses the most dangerous

threat.

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Chapter 8: CDC and American lung association take

on hookah

Hookah smoking is becoming increasingly popular across the country,

particularly among metropolitan youth, college graduates, and working

professionals. Despite their increasing appeal and the implementation of local

and state smoke-free workplace rules, hookah bars are mostly unsupervised.

Furthermore, most hookah smokers believe the habit is less dangerous than

smoking cigarettes. This is concerning for global health because research

reveals that shisha smoking has a number of the similar health hazards as

smoking cigarettes and is related to a number of the similar ailments. While

the American Lung Association as well as its health care collaborators fight to

safeguard consumers and workers from dangers of smoke exposure, it is

essential to consider the health hazards that water pipe usage presents to

young people and adolescents.

Shisha smoking has grown in popularity due to the proliferation of enterprises

that lease shisha and offer flavoured tobacco mixes. The rules and

regulations regulating the usage of shisha in common areas differ by state

and, in certain cases, by locality. Shisha bars and cafés are excluded from

smoke-free rules in several municipalities. Given the substantial research

available regarding the risks of cigarette smoke, strict laws limiting shisha

smoking, particularly amongst young, are necessary to tackle this developing

danger to public health.

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Centers for Disease Control and Prevention:

Based on a research reported inside the 2012 issue of the CDC's Preventing

Chronic Disease, several hookah smokers users believe that hookah

smoking is less dangerous than smoking a cigarette. Shisha smoke, in

contrast, includes a number of the identical carcinogens as cigarette and is

linked to lung disease, respiratory disease, a low birth weight, and

periodontitis.

Another way of reducing hookah usage, as per a research reported in the

CDC's Preventing Chronic Disease titled “ Opportunities for Policy

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Interventions to Reduce Youth Hookah Smoking in the United States", would

be to educate youths about the detrimental health consequences connected

with smoking hookah. This research advises that tobacco items and ad

campaigns should also include health warnings.

The CDC also regularly monitors the current hookah usage among different

age groups and communities. It regularly advises the public and government

to have adequate rules and regulations framed to prevent hookah usage. Its

studies and regular campaigns have had a somewhat positive result. It also

reckons that there is a greater need for mass education drives, particularly

among the young adolescents, that focus on the detrimental effects of

tobacco usage with emphasis on health hazards posed by hookah usage.

American Lung Association

The American Lung Association has been conducting studies and research

for years about the harmful effects of hookah usage on human health. It has

also carried out various campaigns to educate people about the negative

impacts of hookah. Here are certain recommendations for strategies that need

to be devised in order to reduce hookah usage in the United States.

 Smokefree laws in many states entail special exceptions which enable

shisha venues to proceed to enable smoking hookah. Shisha bars may be

classified as tobacco stores, private clubs, or owner-operated

organisations in a few states and localities. Provision for hookah lounges

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must be shuttered in current legislation whenever applicable, and new

comprehensive smoke - free place of work laws should not include them.

 Waterpipes must be explicitly included in government smoking

interpretations. A few states have utilized this vulnerability to explicitly

excluded shisha bars from rules forbidding smoking in public areas and

places of work.

 The Food and Drug Administration, United States, should affirm

jurisdiction over the production and distribution of tobacco utilised in

hookahs, and place restrictions on such goods as necessary to safeguard

public health.

 Eliminate flavours and aromatic use in shisha tobacco by

creating governmental, state, or regional legislation. Flavours have been

one of the aspects related to rising use among young adults and

adolescents. The prohibition of flavours is expected to reduce the

attraction of shisha smoking.

 Minors are permitted to enter premises where shisha are used because of

varied definitions of smoking in few localities. Ending such gaps would

then assist in preventing youths from acquiring shisha, tobacco or similar

products.

 Shisha restaurants and cafes could be restricted by licencing and zoning

criteria for selling tobacco, liquor, or meals, operation hours, costumer

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age, and musical performances . Tobacco consumption as well as the

selling of alcoholic beverages and food on the venue are prohibited in

certain localities. Shisha bars and lounge areas near university campuses

may be prohibited by zoning laws.

Alternative initiatives to dissuade hookah consumptions must be thought

about in extension to the policy proposals stated above. Restricting adverts in

university publications or webpages can dissuade young adults from visiting

shisha lounges. Furthermore, awareness initiatives which illustrate the health

impacts of shisha and spread awareness regarding their lower damage (when

particularly in comparison to smoking cigarettes) might assist building support

from the public for even more stringent laws.

A variety of approaches are required to overturn the rapidly increasing pattern

of shisha consumption in the United States. A holistic plan to restricting shisha

usage is crucial to reversing a highly dangerous phenomenon. Shisha

smoking is indeed a rising public issue that might result in a rise in tobacco

usage in vulnerable groups.

The American Lung Association and the Centers for Disease Control and

Prevention both suggest that legislations forbidding cigarette and other

tobacco-product use in public areas should extend to shisha/hookah as well.

Shisha use ought to be restricted, particularly between young adults and

teenagers.

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Chapter 9: Hookah contribution to Air Pollution

Smoking hookah contributes significantly to the environment's poor air quality.

Numerous Hookah bars had hazardous concentrations of airborne particles,

nicotine, and carbon monoxide, according to air quality studies. Hookah

produces significantly more pollution in the air compared to cigarettes and

vapes, putting customers and workers at greater danger of second-hand

smoke poisoning.

Furthermore, the usage of charcoal to burn tobacco generates high levels of

carbon monoxide, heavy metals, as well as other contaminants into the

atmosphere. Water pipe is extremely toxic, not just for the user, but also to

youngsters, pregnant women, and other nonsmokers.

Hookah consumption has been steadily rising in the United States and all over

the world over the last couple of years. Individuals aren't quite as conscious of

the dangers as they ought to be, and several wrongly assume that running

smoke across water would decrease the threats to their health. Even though

the smoke has been filtered via water, making it cool and gentler to inhale, it

nevertheless includes several of the identical toxins as tobacco smoke. Using

a shisha at home exposes the smoker and all family members at peril of

tobacco-related sickness.

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To figure out the impact of Shisha smoke on enclosed spaces, tests were

performed, and they discovered that, along with Shisha smoke, carbon

monoxide proportions averaged 11 ppm, and Pm2.5 concentrations seem to

be 489 mg / m3 of air, despite the fact that just four active Shisha users were

in the space. Meanwhile, carbon monoxide concentrations in no-smoking

spaces ranged 1.5ppm, and PM 2.5 concentrations ranged 93 mcg. As a

result, Shisha smoking contaminates the indoor space, which further

contaminates the air.

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Hookah and smoking cigarettes both degraded the indoor air quality. The

greatest quantities of all contaminants were found in water pipe smoking

areas. CO levels were substantially higher in hookah/shisha smoking areas

compared to cigarette smoking areas or non-smoking dwellings. Furthermore,

Co2 concentration in the areas closest to shisha smoking were higher

compared to the non-smoking and smoking areas of the cigarette smoking

households. PM2.5 levels were also higher in hookah houses compared to

cigarette and non-cigarette smoking dwellings.

Having hookahs while home is really extremely hazardous, not just for the

user, but also for family members. Hookahs are one of the substitute tobacco

options, such as smokeless tobacco, whose usage is rising across the United

States, particularly among young adults.

There is currently no legislative benchmark for black carbon rates, however

the United States Environmental Protection Agency considers vulnerability to

more than 9 parts per million of carbon monoxide over for a 8 hour duration to

be hazardous, and the World Health Organization bounds PM 2.5 vulnerability

in open air air to 35 μg/m3 beyond a period of 24 hours.

World Health Organization (WHO) and Centers for Disease Control and

Prevention (CDC) research shows that hookah smoking releases most of the

same dangerous chemicals as tobacco smoke, including lung disease,

pulmonary sickness, low birth-weight, and periodontitis. The user is exposed

to even more smoke over a greater amount of time during a Shisha smoke

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session. Shisha smokers inhale a greater density of pollutants owing to their

smoking strategy, which includes the regularity of puffs, volume of intake, and

duration of smoking.

Several studies have been carried out to investigate the quantities of second-

hand smoke produced in hookah bars throughout the United States and

Europe. Combustion produces both carbon monoxide as well as fine

particulate particles. Excessive CO concentrations trigger haemoglobin in

bloodstream to lose oxygen, that can induce nausea, breathlessness,

confusion, unconsciousness, and even death.

Fine particulate matter is composed of molecules produced by lamp burning,

cooking, cigarette smoke, fires, and hookah smoke. Such particles can

penetrate deeply into the respiratory system, causing cough, wheezing, and

breathing difficulties. Prolonged exposure to fine particulate matter may lead

to long-term bronchitis, higher lung cancer risk, and heart failure.

The workers working in hookah bars and lunges are more at risk compared to

hookah users and non users. As these workers are exposed to second-hand

smoke for a long time each day, they usually fall prey to tobacco related

health conditions like cancers, tumours, heart conditions, and much more.

To safeguard customers and workers from the hazardous serious health

consequences of cigarettes and hookahs, an overwhelming number of cities

and states are enacting broad clean indoor environment legislation. 35

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American states have approved legislation mandating that all establishments,

including bars and restaurants, be smoke-free.

Hookah use, on the other hand, is not governed by the same rules, and its

usage is presently uncontrolled by the Food and drug administration.

Previously , cigarette exposure estimations in workers had a significant impact

on the establishment of clean air legislation. The severe lack of health data

about secondhand hookah smoking, especially for employees, necessitates

additional study in this field in order to develop proof-backed laws on hookah

use throughout bars as well as other public settings.

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CONCLUSION

Hookah inhalation doesn't really cause intoxication. This does, however, pose

numerous major hazards and is addicting, similar to smoking cigarettes.

Shisha smoking is also not any safer than inhaling tobacco. If anything, it is

one of the most hazardous methods of tobacco consumption. Its momentarily

relief leads to permanent and long-lasting damage to the human health.

Increased amount of research is required:

Despite the fact that hookah has existed for generations, much fewer

research has been done on its chemical contents and quality of air in

comparison to cigarettes. Because tobacco is the major source of toxic smoke

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in hookah as well as cigarettes, hookah consumers are subjected to a variety

of harmful compounds as cigarette smokers, however at far larger

concentrations, that might result in individuals experiencing exacerbated

health implications. As a result, it is critical to assess the primary chemicals

emitted by hookah vapes in an effort to assist in the evaluation of both chronic

and acute health consequences.

Many studies and research has been conducted in different parts of the world

to show the hazardous impertinent impact of hookah consumption on

smokers, non-smokers, and on the environment. Such studies have been

significant in making people aware of the dangers and helping them to give up

hookah. However, there is still a greater requirement for an increased number

of studies and research to show just how dangerous hookah smoking is.

Governments and organisations need to take the necessary steps to facilitate

and encourage similar studies and, at the same time, allocate funds for them.

Usage has been increasing day by day:

Latest studies demonstrate that, as with cigarettes, hookah is much more

accepted in society, and so as a result, there are very few education and

awareness initiatives aimed at informing the people about the addicting and

detrimental to wellness nature of hookah. This is why hookah usage among

young adults, primarily women, has grown significantly in last several years.

Hookah usage has also increased among pregnant women, who continue to

smoke hookahs throughout their pregnancy.

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Many people believe that water pipe smoking is not hazardous to their well-

being or isn't as bad as the other forms of tobacco. There might be lack of

large amount of research regarding this, but one thing is substantially clear in

the studies conducted that hookah smoking is way worse than cigarette

smoking. Moreover, hookah smokers are more likely to start cigarette

smoking.

Hookah: reason behind numerous deadly diseases

Hookah smoking, like cigarette smoking, delivers several toxic substances

and radicals into the human body, most of which have been linked to cancer

progression. According to one research, consuming hookah multiplies the

chances of lung cancer in comparison to nonsmokers. Other investigations

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found a link between shisha use and tumours, ovarian cancer, squamous cell

cancer and complicated disease of the lip, and nasopharyngeal disease.

If you believe you could be hooked to hookah smoking, speak with your health

physician about a stop smoking programme that will assist you in quitting.

Additionally, smoking hookah poses a cardiovascular danger, resulting in an

immediate rise in blood pressure, pulse rate, and Carbon monoxide levels.

Several research have reported a decrease in variability in heart rate caused

by hookah, that might result in a higher chance of coronary artery disease.

This danger might well be enhanced even more by a fall in cholesterol levels

of HDL caused by hookah use. Hookah smoking is also linked to a higher

incidence of infection, specifically tuberculosis, herpes, and cancer. This is

mainly driven by exchanging mouthpieces when smoking, which allows

microbial and dangerous microorganisms to be spread among hookah users.

Healthcare providers need to take action:

Smoking hookah has evolved into a global habit, with such an alarming rise in

use among people of different age groups and sexes. An increasing body of

research has continuously established the risks and negative health impacts

of hookah use. Hookah use, like many other types of tobacco misuse, clearly

carries a major global health danger that doctors are probably

underestimating. Health practitioners who understand hookah and the

dangers could more efficiently detect water pipe users, and counsel people on

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its detrimental consequences, and diagnose pathologic indications of hookah

smoking.

Hence, there is a need for healthcare workers to equip themselves with

hookah usage and its detrimental consequences. Lack of appropriate

knowledge might result in improper treatment and diagnoses. The

government should fund and encourage health care practitioners to

understand and train themselves about this. This would ensure that proper

medical care and advice is given, in addition to enabling healthcare

practitioners to assist their patients in stopping hookah use.

If you are a hookah user, I hope by now you understand how risky and

perilous hookah smoking is. If you struggle with hookah addiction, it is

important that you seek medical attention as soon as possible and enroll in a

rehabilitation centre. Hookah is dangerous. The faster you understand this,

the better it is.

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