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

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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.

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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

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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.

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

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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

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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.

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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.

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

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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.

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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

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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

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

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scientists about hookah as it is not as

widespread as cigarettes.

Chapter 2:Global epidemiology

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.

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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-

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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 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

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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.

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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 majority of people. It is the various

varieties of hookah flavors that appease

people.

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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

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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.

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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. 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.

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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

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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:

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

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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%.

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Time trends:

Using the available data, it is difficult to

construct a clear picture of time evolution

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and how different techniques are used by

different people. However, 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

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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.

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Chapter 3: Contents present in

Hookah

Hookah users frequently believe that hookah

usage is less dangerous than 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

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smell and taste, thereby making them

especially tempting to teenagers.

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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

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

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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

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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

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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.

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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

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glands, where it stimulates the creation of

adrenaline. It is a hormone that aids in the

fight-or-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

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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

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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

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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

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smoker's mouth to another's may increase

the risk of infection from transitional diseases

such as cancer, 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

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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

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causes breathlessness, coughing, bronchitis,

nocturnal coughing, and wheezing.

 Cardiovascular Effects:

The cardiovascular changes are alarming

even with small sections and are consistent

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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.

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 Gastro-esophageal Effects:

A study evaluating the association between

hookah tobacco smoking and GERD found

that among people not using medications

against reflux symptoms, there was an

association between hookah smoking and

severe and frequent GERD.

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 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

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circumference in retrospective cross-model

analysis. Surprisingly, hookah 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

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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,

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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

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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.

Patients who were exposed to CO are

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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

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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

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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 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

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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

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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.

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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 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

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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

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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

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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

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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, 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

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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

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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

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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-

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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 (University of Kufa,

Al-Najaf, Iraq) and Al-Sadr Teaching

Hospital laboratories. This study was

designed to measure the heavy metal

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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

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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

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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. 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.

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The results showed an increase in the level

of iron in smokers' blood compared to non-

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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 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.

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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

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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

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differences of smokers was not significant

and might be related to sample variations.

Chapter 7: Comparison

between Hookah versus other

Tobacco Sources

Tobacco has remained famous for centuries,

and its usage is rising despite apparent

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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

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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:

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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

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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. 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.

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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:

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Despite the dangers associated with pipe

tobacco, having smoked tobacco through a

pipe is a global practice for ages. Pipes have

been traditionally used for ceremonial

purposes, but the practice has gradually

gained conventional popularity throughout

the years.

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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.

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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.

 Cigars:

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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

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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

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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.

As per this calculation, oral consumption of

tobacco can lead to severe health conditions

compared to hookah smoking. It can cause

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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

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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

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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

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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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Centres 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 “

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Opportunities for Policy 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

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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

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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 must be shuttered in

current legislation whenever applicable,

and new comprehensive smoke - free

place of work laws should not include

them.

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 Waterpipes must be explicitly included in

government smoking interpretations. A

few states have utilised 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.

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 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.

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 Shisha restaurants and cafes could be

restricted by licencing and zoning criteria

for selling tobacco, liquor, or meals,

operation hours, costumer 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

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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

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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

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contaminants into the atmosphere. Water

pipe is extremely toxic, not just for the user,

but also to youngsters, pregnant women,

and other nonsmokers.

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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

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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

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all family members at peril of tobacco-related

sickness.

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

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contaminates the indoor space, which further

contaminates the air.

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

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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

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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

session. Shisha smokers inhale a greater

density of pollutants owing to their smoking

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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.

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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

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cancers, tumours, heart conditions, and

much more.

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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 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

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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:

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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 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.

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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.

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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.

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Hookah: reason behind numerous deadly

diseases

Hookah smoking, like cigarette smoking,

delivers several toxic substances and

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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 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

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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.

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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 its

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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.

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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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