1 Aana corresponds to how many Dhuri

Shisha smoking: supposedly better smoking

Shisha bars are springing up like mushrooms in the big cities. Smoking water pipes is trendy. The dangers of the supposedly “healthy” alternative to cigarettes are drastically underestimated.

Photo: alfa27 / stock.adobe.com

If you live in cities like Frankfurt, Berlin or Hamburg, you will find it difficult not to walk past a shisha bar. In recent years, more and more of these bars have opened, especially in metropolitan areas. Example: According to Google Maps, there are already 192 of these locations in the greater Berlin area.

The impression confirms a trend: Shisha smoking (called “hookah smoking” in the USA) is in, cigarette smoking is out. According to the current Tobacco Atlas, almost a third of children and adolescents in Germany between the ages of 12 and 17 have smoked a water pipe, and the trend is rising (1, 2) (see Figure 1). In relation to the entire population, it is one in six.

At the same time, pipe tobacco sales almost tripled between 2013 and 2017 (see Figure 2). As a rule, smoking is not carried out daily, but occasionally and in groups, with a session lasting around an hour.

One shisha session is comparable to 100 cigarettes

The amount of nicotine ingested during such a shisha session is comparable to smoking 10 cigarettes - derived from the measurement of the nicotine metabolite cotinine in the urine. If you look at the smoke volume, there are even 100 cigarettes (3).

Critics often complain that this comparison is not permissible because the shisha smoke is diluted and cleaned by the water and is therefore less dangerous despite the higher volume of smoke. “That's not true,” replies Prof. Dr. med. Thomas Eissenberg from Virginia Commonwealth University in the USA. He is considered one of the leading international experts on alternative tobacco products and provides a simple explanation: “The smoke crosses the water in small bubbles, which creates the characteristic 'bubbling'. The surface tension of the bubbles prevents the smoke from coming into contact with the water. So there is no so-called cleaning either. "

Dr. Katrin Schaller from the WHO Collaboration Center for Tobacco Control at the German Cancer Research Center (DKFZ) in Heidelberg: “This is a widespread misconception. The smoke is only cooled by being passed through the water, which makes inhalation easier. "

The toxic and carcinogenic combustion products resulting from the smoldering of the tobacco therefore reach the lungs completely unfiltered. "Due to the larger volume of smoke, the consumer ingests a significantly larger amount of pollutants than when smoking a cigarette," says Schaller.

More pollutants than in cigarette smoke

This is also confirmed by measurements by Eissenberg. He was able to show that shisha smokers inhale a concentration of carcinogenic polycyclic aromatic hydrocarbons (PAH) that is around 46 times higher than when smoking a cigarette (4). “And the amount of volatile aldehydes is around 13 times as high,” explains the scientist.

These are just a few of the substances that arise when smoking shisha. "Water pipe smoke contains at least 82 harmful substances, including 27 that are carcinogenic or suspected of causing cancer," said Schaller. In addition to the PAHs and aldehydes already mentioned, tobacco-specific nitrosamines, volatile organic substances such as benzene and heavy metals such as nickel, chromium or lead were also detected in the smoke (2).

A recently published meta-analysis of 50 studies summarizes the health dangers of this toxic cocktail (5): Regular shisha smoking led to significantly more respiratory diseases. Chronic obstructive bronchitis (COPD) occurred around 1.2 to 8 times as often.

The risk of lung cancer was 1.3 to 3.4 times higher. The probability of developing oral tumors was even greater (2.5 to 6.9 times). The risk of cardiovascular disease also increased by a relative 30–120%. Another study was able to show that shisha smoking is associated with an up to 70% higher risk of heart attack, while regular cigarette smoking increases the risk by up to 115% (6).

Schaller adds: "If pregnant women smoke shisha, this increases the risk of the child being born with a low birth weight." Last but not least, women increase their risk of developing osteoporosis through regular consumption of water pipe tobacco (2).

Shisha consumption triggers the cigarette

The risk of addiction is also underestimated. And this despite the fact that the addiction potential of nicotine-containing shisha smoke has been clearly confirmed (7). It is unclear, however, whether it is just as addictive as cigarette smoke. Schaller suspects that the addiction potential is comparable to that of the cigarette, even if there are no tangible data to date. “However, we know that adolescents can develop symptoms of dependency even if they consume water pipes every week,” says Schaller.

Eissenberg sees another problem: "The results of some studies show that shisha smokers sooner or later also take up cigarettes." In fact, 2 high-ranking published studies have proven this connection (8, 9). So today's shisha smokers could be tomorrow's cigarette smokers.

Shisha tobacco producers therefore offer nicotine-free tobacco as an alternative. “We tested that too,” says Eissenberg. "In fact, we could not detect any nicotine, but heating the tobacco produced the same pollutants that we found in normal tobacco."

Danger to life from carbon monoxide poisoning

A particular problem with Shi-sha smoke is the high proportion of carbon monoxide. “Our measurements show that shisha smokers inhale the amount that is in an average of 8 cigarettes during a session,” Eisenberg states (4).

This can be a problem, especially in stuffy shisha bars. If there is no ventilation, the colorless and odorless gas collects in the room air. The result can be life-threatening carbon monoxide poisoning. In Germany, according to newspaper reports, CO poisoning occurs again and again in shisha bars. "So far, there are no tangible data on the incidence," says Schaller. According to a press release from the University of Düsseldorf, however, CO poisoning from smoking shisha has increased (10).

There are 54 case reports on the subject in the literature (11). In half of the studies, those affected lost consciousness; in some cases, those affected did not smoke shisha at all. If the symptoms are severe, hyperbaric oxygen therapy must be carried out. In order to reduce the risk to a minimum, it should therefore be stipulated that every shi-sha bar provides adequate ventilation and that appropriate air conditioning systems are installed.

The rumor of healthier shisha smoking

Despite the toxins released by smoking hookah, many consumers maintain the misconception that smoking a water pipe is healthier than smoking traditional cigarettes. There are several reasons for this - in addition to the already discussed misconception that the smoke is cleaned by the water - Shisha tobacco is offered in countless flavors, from apple to cucumber to cinnamon. More exotic varieties such as goat cheese and bratwurst are also in circulation. The taste, which is often advertised as “fruity and refreshing”, and the cool smoke - which, by the way, only consists of water vapor to a very small extent - suggest a deceptive “harmlessness”.

It is also often claimed that shisha tobacco is free from tar. “That is true, but it is misleading,” said Eissenberg. “Tar only arises when the tobacco is heated, be it in the cigarette or in the shisha.” In addition, many smokers do not know what tar actually is. “By definition, the term tar includes all substances except nicotine and water that are produced during tobacco burning,” says the scientist.

These medical facts can currently do little to counter the “coolness factor” of the water pipe. The main reason for the trend: Shisha smoking is part of the German rap culture. Big names in the scene such as Haftbefehl, KC Rebell, Sun Diego and Kool Savas have even launched their own tobacco varieties, which they actively promote in their music videos. Many young people see them as role models.

Some rappers also opened shisha bars and shi-sha shops themselves. Business seems to be booming. It remains to be seen that smoking shisha is by no means the healthier alternative to smoking cigarettes. The potential for dependency is similar, and pollution levels are even higher. In daily practice, doctors should therefore explicitly ask adolescents and young adults in particular about water pipe consumption and point out the associated health risks. Dr. med. Tim Hollstein

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Photo: Thomas Gowanlock / 123RF

The shisha

The water pipe, originally from the Arab-Indian region, consists of 4 parts: a water vessel (bowl), a column of smoke, a head and a hose. The tobacco is placed on the head and perforated aluminum foil is stretched over it. Glowing charcoal is now placed on the aluminum foil, which makes the damp shisha tobacco smolder. The resulting smoke is passed through the water container and inhaled through the hose. So that the tobacco does not dry out, it is mixed with very large amounts of glycerine as a humectant.

Orth B, Merkel C: The decline of cigarette smoking among adolescents and young adults in Germany and the rising relevance of waterpipes, e-cigarettes and e-hookahs. Federal Health Gazette Health Research Health Protection 2018; 61: 1377-87 CrossRefMEDLINE
German Cancer Research Center (Ed.): Tabakatlas Deutschland 2015. Lengerich: Pabst Science Publishers 2015. https://www.dkfz.de/de/tabakkontrolle/download/Publikationen/sonstVeroeffnahmungen/Tabakatlas-2015-final-web-dp-small. pdf (last accessed on 6 January 2019).
German Cancer Research Center (Ed.): Wasserpfeifen. Facts about smoking, Heidelberg, 2018. https://www.dkfz.de/de/tabakkontrolle/download/Publikationen/FzR/FzR_2018_Wasserpfeifen.pdf (last accessed on 6 January 2019).
Eissenberg T: Tobacco smoking using a waterpipe (hookah): what you need to know. AANA J 2013; 81: 308-13 MEDLINE PubMed Central
Waziry R, ​​Jawad M, Ballout RA, Al Akel M, Akl EA: The effects of waterpipe tobacco smoking on health outcomes: an updated systematic review and meta-analysis. Int J Epidemiol 2017; 46: 32-43 MEDLINE
Platt DE, Hariri E, Salameh P, et al .: Association of waterpipe smoking with myocardial infarction and determinants of metabolic syndrome among catheterized patients. Inhal Toxicol 2017; 29: 429-34 CrossRefMEDLINE
Aboaziza E, Eissenberg T: Waterpipe tobacco smoking: what is the evidence that it supports nicotine / tobacco dependence. Tob Control 2015; 24 (Suppl 1): i44-53 CrossRefMEDLINE PubMed Central
Soneji S, Sargent JD, Tanski SE, Primack BA: Associations between initial water pipe tobacco smoking and snus use and subsequent cigarette smoking: results from a longitudinal study of US adolescents and young adults. JAMA Pediatr 2015; 169: 129-36 CrossRefMEDLINE PubMed Central
Watkins SL, Glantz SA, Chaffee BW: Association of Noncigarette Tobacco Product Use With Future Cigarette Smoking Among Youth in the Population Assessment of Tobacco and Health (PATH) Study, 2013-2015. JAMA Pediatr 2018; 172: 181-7 CrossRefMEDLINE PubMed Central
Dreising S: Carbon monoxide poisoning from hookah smoking is on the rise: around 100 treatments in the special pressure chamber at the UKD this year. Press release from Heinrich Heine University Düsseldorf 2017. https://www.uni-duesseldorf.de/home/nc/startseite/news-detailansicht-inkl-gb/article/kohlenmonoxidvergiftungen-durch-shisha-rauchen-haben-zu- already-around-100-treatment-in-der-speci.html (last accessed on 6 January 2019).
Retzky SS: Carbon Monoxide Poisoning from Hookah Smoking: An Emerging Public Health Problem. J Med Toxicol 2017; 13: 193-4 CrossRefMEDLINE PubMed Central