Reader Submission | Rise of Shisha: From Middle Eastern Cafés to Globally Popular Tobacco Product

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The waterpipe, known as narghileh, shisha, hookah, hubble-bubble, and bong in different countries, is a popular device for smoking tobacco.

The World Health Organization (WHO) defines Waterpipe Smoking (WTS) as "a method of tobacco consumption using a single or multiple pipe(s) to smoke flavored or non-flavored tobacco, with the smoke passing through water or another liquid before reaching the smoker." Some countries have their own definitions of waterpipe smoking.

The origin of WTS is still unclear. In the late 19th century, it was popular among elderly men in the Middle East, but with the introduction of sweet and flavored tobacco in the early 1990s, WTS quickly gained popularity among young people and spread globally through universities and schools.

As the coffee shop culture in the Middle East and around the world continues to grow, the social acceptance of hookah has been on the rise. Hookahs in cafes, restaurants, and bars have become a focal point for young people's social gatherings, as a group of friends can share a hookah for a long period of time due to its slow smoking pace. Tourists have taken the habit of smoking hookah back to their countries, and migrants from the Middle East have opened hookah cafes and restaurants around the world. This way, hookah has spread beyond the Middle East and become integrated into the global tobacco market. Although other regions have restrictions on tobacco advertising, products have been promoted throughout the Middle East via satellite TV, the internet, and social media. Since these media are largely unregulated, the industry is able to circumvent most advertising bans.

Global Tobacco Company's Expansion Strategy

In history, multinational tobacco companies have shown little interest in hookah tobacco products. Review of tobacco industry documents reveals that, apart from some "hookah-inspired" products that have not become mainstream in the market, tobacco companies have not focused on hookah tobacco and its accessories.

This situation persisted until 2012 when Japan Tobacco International (JTI) acquired the Egyptian company Al Nakhla. At that time, Al Nakhla was the world's largest manufacturer of waterpipe tobacco products. However, even so, this was seen as a strategy to increase cigarette sales.

In 2019, Philip Morris International (PMI) applied for a patent for a "smokeless device for heating a substrate without combustion." However, as of 2023, the product has not yet been released to the market.

Usage of Waterpipe

When smoking a hookah, use the device shown in Figure 1. As the smoker inhales from the mouthpiece, a piece of lit charcoal heats the tobacco in the head of the device. This heat produces smoke, which passes through the body of the device and enters the water-filled bowl. The smoker inhales the smoke by sucking through the hose connected to the top of the bowl, pulling the smoke into the water to create bubbles, and finally inhaling the smoke through the mouthpiece. Typically, the head is filled with flavored and sweetened tobacco separated from the charcoal by perforated aluminum foil. While specific designs and features may vary by region, the basic principle remains consistent: smoke filtration through water.

Electronic hookah pipes or electronic hookah pens are not traditional hookah devices, as they do not involve burning charcoal. They are classified as electronic nicotine devices, similar to electronic cigarettes, in which a liquid solution is heated by electricity to produce an inhalable vapor.

Role of Flavor

Traditionally, hookah tobacco (WT) was made using flavorless tobacco leaves (Ajami, Tumbak, or Jurak). However, since the 1990s, flavored tobacco has become increasingly popular.

The most common type of flavored tobacco for waterpipe smoking is Maassel (or Mo'assel), which is a "honey" tobacco made up of one-third tobacco and two-thirds honey and fruit flavors. It is typically a mixture of tobacco, molasses (a thick syrup made from raw sugar), glycerin, and fruit flavors. A study among Lebanese adults showed that the introduction of new tobacco flavors prompted people to start waterpipe smoking and increased its usage. Similarly, a study in Iran found that various "enticing" flavors led to an increase in waterpipe tobacco smoking among adolescents and women.

In addition, a study in the UK found that people mistakenly believe that tobacco smoke is safer than cigarettes, "because it has a pleasant smell and fruity flavor.

Health Impact

Evidence suggests that hookah, like other tobacco and nicotine products, is addictive.

Like cigarettes, hookahs are also toxic and carcinogenic. A study found that hookah smoke contains 27 known or suspected carcinogens. Because hookahs are often shared, they can also serve as a way to spread infectious diseases, which is particularly concerning during the COVID-19 pandemic. Therefore, hookah use has both short-term and long-term health effects on users and can also harm those exposed to secondhand smoke.

Many user groups believe that hookah smoke, filtered through water, poses less harm than cigarette smoke. This belief has led to a rise in popularity and acceptance of hookah.

However, hookah smoke contains similar or even higher levels of toxic substances compared to cigarettes, which can have the same effects on cells as traditional products, including lung and artery diseases.

Market Penetration Rate

A systematic review in 2018, which included 129 studies from 68 countries, found that the prevalence of waterpipe tobacco smoking (WTS) was highest among adults in the Eastern Mediterranean Region (EMR). However, among youth, the rates of WTS were similar in Europe and the EMR. By comparing the WTS rates of adults and youth, the study suggests that globally, youth have a higher smoking prevalence.

The World Health Organization released a consultation report on WTS in 2015, stating that although WTS traditionally has been associated with the Eastern Mediterranean region, Southeast Asia, and North Africa, it is now spreading among adults worldwide. Additionally, the World Health Organization also noted that the growth of WTS among primary and university students is particularly rapid.

Laws and Regulations

In many high-income countries, waterpipe tobacco smoking products are not subject to the same tobacco control policies. In many low-income countries, even if there are policies in place, enforcement is often weak. While flavoring is a major draw for young people, flavor bans typically do not cover waterpipe tobacco products. As a result, the global growth of waterpipe tobacco smoking is largely unregulated.

The World Health Organization Framework Convention on Tobacco Control (WHO FCTC) defines tobacco products as "any product entirely or partially made of leaf tobacco as a raw material, which is manufactured to be used for smoking, sucking, chewing or sniffing." This definition includes waterpipe tobacco products. The WHO FCTC specifically issued a decision on waterpipe tobacco control during the Conference of the Parties.

• At the third Conference of the Parties (COP3) in 2008, parties were invited to consider introducing health warnings and information on tobacco packaging (including waterpipe packaging), and to take innovative measures requiring health warnings and information to be printed on tools used for waterpipe smoking. 
• In 2014, the sixth Conference of the Parties (COP6) invited parties to strengthen the implementation of the WHO Framework Convention on Tobacco Control regarding waterpipes, including monitoring the use of waterpipes and researching their market. This decision also invited the Convention Secretariat to collaborate with the World Health Organization to support countries in regulating waterpipes. 
• The seventh Conference of the Parties (COP7) in 2016 provided more detailed instructions to parties, including the prohibition of flavorings in waterpipe products. 
• The eighth Conference of the Parties (COP8) in 2018 made decisions on the implementation of Articles 9 and 10 of the Convention (regarding the contents and disclosure of tobacco products, including waterpipes, smokeless tobacco, and heated tobacco products), including establishing an expert group to study the reasons for the low implementation rates of Articles 9 and 10.

In January 2016, the World Health Organization Framework Convention on Tobacco Control Secretariat signed a memorandum of understanding with the American University of Beirut, making it a global knowledge center for the convention, particularly in the areas of education, research, and dissemination of information that supports the implementation of the convention.

In 2018, the WTS Knowledge Center submitted a report to the World Health Organization at the Eighth Conference of the Parties to the Framework Convention on Tobacco Control, summarizing the provisions made by Parties regarding waterpipe tobacco use. The report was updated in 2022 and found that out of the 90 countries reviewed, over half (47 countries) had implemented policies related to waterpipe use. The majority of these policies (almost 45%) were in Europe, with around 21% in the Eastern Mediterranean Region.

During the COVID-19 pandemic, many countries have temporarily banned the use of hookah in order to prevent the spread of the virus. In the Eastern Mediterranean Region alone, 17 countries have prohibited the use of hookah in public places.

Hookah and heated tobacco products are not subject to the flavor ban imposed by the 2014 European Tobacco Products Directive (TPD) and implemented in the European Union in 2020. A new directive was issued in 2022 and will take effect in 2023, removing exemptions and bringing regulation of these products in line with cigarettes and hand-rolled tobacco. This means that flavored hookah tobacco will no longer be legal for sale in the EU.

Hookah Market

The advocacy organization "It Is Still Tobacco" estimates that between 2016 and 2017, 54% to 69% of global hookah tobacco products were sold in the Middle East and Africa (MENA) region.

Market analysis firm Valuate also estimates that the global hookah tobacco product market remains concentrated in the Middle East and Africa. They state that the second-largest market share is held by Europe. Valuate estimates that the global hookah tobacco product market was valued at over $800 million in 2022 and predicts that the market size will nearly double by 2029.

Market research company Euromonitor International estimates hookah product sales as part of the broader pipe tobacco category, making it difficult to specifically estimate the global market share of hookah tobacco. However, specific hookah brands can be identified within the data. In 2022, JTI and Al Fakher held the largest share, accounting for nearly 13% of the entire pipe tobacco market, followed by Al Fakher and Eastern brands (including Moassel), with approximately 12% and 8%, respectively.