Waterpipe

Background

Waterpipe has different names in different countries such as narghileh, shisha, hookah, hubble-bubble, or goza. The World Health Organization (WHO) defines waterpipe tobacco smoking as “a form of tobacco consumption that utilizes a single or multi-stemmed instrument to smoke flavoured or non-flavoured tobacco, where smoke is designed to pass through water or other liquid before reaching the smoker”.¹

The origin of waterpipe tobacco smoking is somewhat unclear. In the late 19th century, it was popular among older men in the Middle East who used the harsh non-flavoured form of it, but with the introduction of sweetened and flavoured tobacco in the early 1990’s, Waterpipe use surged among youth, and expanded over all countries and continents, through universities and schools.² Waterpipe use has spread beyond the Middle East and become integrated into the global tobacco market. This was marked by the acquisition of Al Nakhla in 2012, at the time the world’s largest waterpipe tobacco manufacturer based in Egypt, by Japan Tobacco International (JTI).³

Waterpipe tobacco is smoked using a device similar to that in image 1. When the smoker inhales a piece of lit charcoal heats the leaf tobacco in the head, producing smoke which goes through the body of the device into the water bowl. The smoker sucks the smoke through the water, creating bubbles, through the hose fixed on the top of the bowl, and inhales the smoke through the mouthpiece. The head is usually filled with sweetened and flavoured tobacco and separated from the charcoal by perforated aluminium foil. The design and features vary from region to region, but the main principle is that the smoke passes through water.⁴

Evidence shows waterpipe is addictive, the smoke is toxic and carcinogenic. and it is a mode of transmission for communicable diseases. It has both a short-term and long-term harmful health impact on people who use it, and there are additional harms caused by second-hand smoke.^{5 1}

Prevalence

According to a WHO advisory note about waterpipe, published in 2015, although waterpipe smoking was traditionally associated with the Eastern Mediterranean region, Southeast Asia and Northern Africa, its use is growing globally among youth and adults of both genders. Use is particularly increasing among schoolchildren and university students. Research in the WHO advisory note shows that:⁶

African region: Research in South Africa shows that 20% of poor high-school students use waterpipe daily, and 60% of reported ever having used one.⁷ A study in Western Cape reported higher figures: 40% current use, and 70% ever use.⁸ Even among medical students, use is relatively high; a study in Pretoria found that nearly 20% of participants had used a waterpipe at some time.⁹

Region of the Americas: Although there is limited research on waterpipe in Latin America, some has been conducted in the United States (US) and Canada. In US a national study of the 104,434 university students shows that after cigarette smoking, waterpipe smoking was the most frequent form of tobacco use (8.4%, compared to 29.7% for cigarettes), and over 30% reported using waterpipe at some time.¹⁰ In Canada, although cigarette smoking among young people had significantly decreased, waterpipe use increased by 2.6% among young people between 2006 and 2010.¹¹

Eastern Mediterranean Region: This region has the highest prevalence of waterpipe use. Studies (1999 – 2008) suggest that waterpipe use was more frequent than cigarette smoking among children aged 13–15 in most countries of the region,¹² and increasing in multiple countries, with prevalence ranging from 9% to 15%.¹³

European Region: Among people aged 15 years or over, 16% had tried waterpipe at least once. Some studies suggest waterpipe prevalence of 42% in Latvia, 37% in Estonia, 36% in Lithuania, 8% in Malta, 8% in Spain, 5% in Ireland and 5% in Portugal. A sharp growing prevalence in waterpipe use was reported in Austria, the Czech Republic and Luxembourg.¹⁴

South-East Asia Region: Waterpipe “hookah” bars and restaurants are becoming increasingly common and are most often frequented by young people. Studies (2008 – 2011) suggest that waterpipe prevalence among men was just over 1% in Bangladesh, and in India, and much lower in in Indonesia and in Thailand (0.3%). Fewer than 1% of women use waterpipe in India Bangladesh, India, Indonesia, and Thailand.^{15 16}

Western Pacific Region: Waterpipe is called “bong” and is different in design from the popular Middle Eastern waterpipe, and therefore is often not included in waterpipe studies. It can be made of bamboo, metal or glass and are used in countries such as China, the Lao People’s Democratic Republic, Myanmar and Vietnam. In 2010 in Vietnam around 13% of males aged or over 15 used bong.¹⁷

Regulations

The WHO Framework Convention on Tobacco Control (WHO FCTC) identifies tobacco products as “products entirely or partly made of the leaf tobacco as raw material which are manufactured to be used for smoking, sucking, chewing or snuffing”.¹⁸ This definition covers waterpipe tobacco products as well. The Conference of Parties (COP) of WHO FCTC issued decisions specifically for waterpipe tobacco control:

• At COP3 in 2008, Parties were invited to consider introducing health warnings and messages on tobacco packages, including waterpipe, and to use innovative measures requiring health warnings and messages to be printed on instruments used for waterpipe smoking.¹⁹
• At COP6 in 2014, Parties were invited to strengthen the implementation of WHO FCTC on waterpipe, including conducting surveillance of its use and research on its market. This decision also invited the Secretariat of the Convention to work with the WHO to support countries in waterpipe control.²⁰
• At COP7 in 2016, more detailed instructions were given to Parties, including to ban the use of flavourings in waterpipe tobacco products.²¹
• At COP8 in 2018, there is a decision on the implementation of Articles 9 and 10 of the WHO FCTC (Regulation of contents and disclosure of tobacco products, including waterpipe, smokeless tobacco and heated tobacco products), including the establishment of an expert group to examine the reasons for low implementation of Articles 9 and 10 of the Convention.²²

In January 2016, the Secretariat of the WHO FCTC signed a Memorandum of Understanding with The American University of Beirut making it the global knowledge hub for waterpipe smoking, in particular with respect to education, research, and the dissemination of information that contributes to the implementation of the Convention. ²³

In 2018, the knowledge hub submitted a report to the WHO FCTC COP8 that summarizes Parties’ regulations concerning waterpipe as listed in the below table: ²⁴

Country	Smoke Free Policies	Text Warning Label	Pictorial Warning Label	Waterpipe Specific Health Warnings
African region
Ghana	Yes	Yes	No	No
Kenya	Yes	Yes	Yes	No
Nigeria	Yes	Yes	No	No
Rwanda	Yes	Yes	No	No
Uganda	Yes	Yes	No	No
United Republic of Tanzania	Yes	Yes	No	No
Region of the Americas
Belize	No	Yes	No	No
Brazil	Yes	Yes	Yes	Yes
Canada	Yes	Yes	Yes	No
Colombia	Yes	Yes	Yes	Yes
Jamaica	Yes	Yes	Yes	No
Panama	Yes	Yes	Yes	Yes
United States of America	Yes	Yes	No	No
Eastern Mediterranean Region
Afghanistan	Yes	Yes	Yes	No
Bahrain	Yes	Yes	Yes	Yes
Egypt	Yes	Yes	Yes	Yes
Lebanon	Yes	Yes	No	Yes
Pakistan	Yes	Yes	Yes	No
Saudi Arabia	Yes	Yes	Yes	No
United Arab Emirates	Yes	Yes	Yes	No
European Region
Azerbaijan	Yes	Yes	No	Yes
Bulgaria	Yes	Yes	Yes	No
Czech Republic	Yes	Yes	Yes	No
Estonia	Yes	Yes	Yes	No
Israel	Yes	Yes	No	No
Germany	Yes	Yes	Yes	Yes
Netherlands	Yes	Yes	Yes	Yes
Norway	Yes	Yes	Yes	No
Portugal	Yes	Yes	Yes	Yes
Russian Federation	Yes	Yes	Yes	No
Serbia	Yes	Yes	No	No
Slovakia	Yes	Yes	Yes	Yes
Slovenia	Yes	Yes	No	No
Turkey	Yes	Yes	Yes	Yes
Ukraine	Yes	Yes	Yes	No
United Kingdom	Yes	Yes	Yes	No
South-East Asia Region
India	Yes	Yes	Yes	No
Western Pacific Region
Japan	Yes	Yes	No	No
Philippines	Yes	Yes	Yes	No
Republic of Korea	Yes	Yes	No	Yes

During the COVID19 pandemic in 2020, many countries temporarily banned the use of waterpipe in their efforts to stop the spread of the infection. Countries implementing a ban included Iraq, Jordan, Kuwait, Oman, Palestine, Qatar, Saudi Arabia, Syria, Tunisia, and UAE. ²⁵

Industry and Brands

In 2018, according to the WHO FCTC, waterpipe was reported to be on the market in 70% of countries, compared to 60% in 2016. ²⁶

Due to weak regulations and lack of industry transparency, it is difficult to identify all brands of waterpipe and the companies that own them. The following table shows some brands of waterpipe used all over the world classified according to country of production. However, little information is available on the ownership, management, or the market size of each of them:

Country of production	Brand
Egypt	Al Nakhla (owned by JTI) 27 | Eastern Tobacco: (Maasel, Saloum, Crystal) produced by Eastern Company28
Germany	187 Tobacco29 | Aeon30 | Al Wazir Tobacco31 | Anonymous Tobacco-Vendetta32 | Babos Tobacco33 | Black 11 Tobacco34 | Capital Bra Smoke35 | Chaos Tobacco36 | Colonial Tobacco37 | Escobar Tobacco38 | Fibdis Tabak39 | Gama Tobacco40 | Gentleman Smoke41 | Golden Pipe Tobacco42 | Hero Smoke43 | Holster Tobacco44 | Infinity Molasses45 | Lady Smoke46 | Magic Smoke47 | Maridan Tobacco48 | Moloko Tobacco49 | Mytabak50 | NameLess Tobacco51 | Nargilem Tabak52 | Nubia Tobacco53 | Octo Buzz Tobacco54 | Oneway Tabak55 | Rocket Star56 | Rozana Tobacco57 | Shiazo58 | Sinned Tobacco59 | Smokeys Tabak60 | Tombacco61 | Zeynep sein Tabak62
Iran	Al Mahmood63
India	Afzal64 | Jannet El Fawakeh  & Sophie’s (produced by MujeebSons) 65 | Originals (produced by Godfrey Phillips India) 66
Indonesia	Produced by Doobacco: Awards Tabak & Dobacco Gastro67  | O´s Tobacco68
Jordan	360 Tobacco69 70 | 7 Nights71 | Al Rayan Hookah (Alandalus flavoured tobacco & Molassese Co. L.L.C) 72 | Al Tawareg Tobacco73 | Al Waha (Middle East for Tobacco) 74 | Amy Gold75 | Dark Smoke76 | Mazaya (owned by Alzawrae Company) 77 | Romman78 | Skull Tobacco79 | Starbuzz Tobacco80 | Sweet Smoke81
Paraguay	Zomo82
Russia	Darkside83
Turkey	Serbetli84 | Smyrna Tobacco85
UAE	Al Ajamy Gold86 | Al Fakhamah87 | Al Fakher (owned by Jordanian Al Eqbal Investment Company) 88 | Al Safwa89
UK	Savacco90
USA	360 Tobacco (packaging) 69 69 | Alchemist Tobacco91 92 | Azure93 | Cloud Tobacco94 | Eternal Smoke95 | Fantasia96 | Fumari97 | Headquarters Hookah98 |  Haze Tobacco99 | Hookafina100 | Nirvana101 | Othmani102 | Pure Tobacco103 | ROR Tobacco104 | Social Smoke105 | Starbuzz Tobacco106 | Tangiers107 | Trifecta Tobacco108 | Ugly Hookah109 | Xracher Tobacco110 | Zumerret111 |                      Stating to be tobacco free: Beamer112 | Hookahpsule113  | Hydro Herbal114 | Urth tree115

Apart from the waterpipe tobacco industry, there are other industries serving waterpipe use such as those producing the waterpipe devices, charcoal, and their accessories. For example, Alpaca Bowls, Mya Hookah, MYA Saray, Orcamp, World Hookah Market, Project Black, Shika Hookah, Shishabucks, Regal Hookah, Werkbund, Charco Flare, Coco Soul, CocoUrth, King Coco, Narine Charcoal and Deezer. There are also waterpipe cafés and lounges promoting waterpipe use such as Kaloud and Karizma. Additionally, there are distributors, vendors and wholesalers such as Zahrah, Ultimate Hookah Corp., Texas Hookah, Sky Hookah Distribution, Sierra Network, Power Hookah, Hookah Wholesalers, HookahJohn. Such businesses organize events for promotion of waterpipe use such as HookahFair and Hookah Expo. ¹¹⁶

Factors and strategies led to waterpipe popularity

The WHO Study Group on Tobacco Product Regulation (TobReg), has issued advisory notes on water pipers in 2005 and 2015 They also developed a fact sheet in which they give the following 5 reasons for the increasing popularity of waterpipe tobacco smoking, especially among young people: ^{4 6 1}

• Introduction of flavoured tobacco (maassel). In the 1990’s, when sweetened flavoured waterpipe tobacco (commonly called maassel) was introduced, waterpipe use become more popular. Maassel is manufactured by the fermentation of tobacco with molasses, glycerine and fruit essence, producing a moist, pliable mixture. It is believed that flavoured waterpipe started in the Middle East and then spread globally. Flavoured waterpipe is much preferred by youth smokers, compared to the pre-1990s unflavoured form, contributing to the global spread of the product.
• Social acceptability due to the café and restaurant culture. With the surge of café business in the Middle East and globally, waterpipe has become the focus of youth social gatherings, as a waterpipe can be shared by a group of friends over an hour with a slow puff rate. Tourists transferred the waterpipe habit to their countries, with expatriates from the Middle East opening waterpipe cafés and restaurants around the world.
• Promotion through mass communication and social media. It is believed that two inventions used by the industry have contributed to the spread of waterpipe use. The first is the unregulated, inexpensive, widely accessible satellite television media that helped promote waterpipe use throughout the Middle East. The second is the internet that helped in promoting the use of waterpipe at a global level. The largely unregulated internet gives opportunities to the industry to circumvent most advertising bans and reach their preferred customer groups.
• Lack of waterpipe-specific policy and regulations. In many developed countries, waterpipe products are exempted from tobacco control policies, and in many developing countries, even if there is a policy, enforcement is very weak. Consequently, the use of waterpipe has proliferated globally, largely unchecked. Although, for example, flavouring is a major factor in the appeal to young people, bans on the use of flavours in tobacco often do not cover waterpipe tobacco products.
• Erroneous perceptions about the relative safety of waterpipe smoking. Among many groups of users there is a belief that the smoke of waterpipe is filtered in water making it less harmful that cigarette smoking. This false belief led and is leading to a growing popularity and acceptance of waterpipe use.