Most people seem to think it's safer but, asks Hala Sakr, is the shisha any healthier than its ubiquitous counterpart? "Today we ordered 30 shishas [water pipe] all at once," my 15-year-old son Ahmed reported, amused. It was the last day of school, an occasion to gather in a café to watch the evening's World Cup match -- perhaps also the start of the summer routine? Voicing my worry, choked, was all I could do. "Don't start, I wasn't part of this," he said. "I've only smoked shisha three times in my whole life." Which is when his sister Laila, 19, intervened: "Come on, it's only normal. There's nothing bad about shisha. Besides, they have very nice flavours." Evidently neither of them was aware of the health risks involved; like most people, indeed, my children would never suspect that shisha could be as bad as cigarettes. "People order it the way they order fizzy drinks or ice cream," Laila looked wide-eyed. So they do, do they... According to Fatema Al-Awwa, regional advisor of the Tobacco Free Initiative, Eastern Mediterranean Regional Office of the World Health Organisation (WHO), "there is much misunderstanding regarding tobacco products other than cigarettes. Yet the truth is clear: all tobacco products are dangerous and addictive, and every effort should be made to discourage their use." Every year the World No-Tobacco Day (WNTD), launched on 31 May 1988, focuses on a new theme, stretching out its activities till the next year. But WHO failed to pick the right day, says Al-Awwa: at least in Egypt, May is a time when school children are busy with exams, which makes it difficult to involve them: "This is too important a group to lose. We tried our best to change the date -- in vain." Indeed this is how the Arab no-tobacco day became 7 November. Appropriately for my own family life, at any rate, this year's WNTD theme is "tobacco: deadly in any form or disguise" -- stressing that chewing tobacco, snuff, cigars, pipes and so called organic cigarettes as well as shisha -- not to mention aluminium nicotine cartridges, computer-chip controlled delivery systems and all such hybrids, with charcoal or without -- are all just as bad as filter- tips. In the words of WHO, indeed, "tobacco addiction is a global epidemic that is ravaging the countries and regions that can least afford its toll of disability, disease, lost productivity and death. This epidemic follows a similar course that has been documented in country after country, driven by an industry that puts profits ahead of life. Now, as nations have begun to fight back and, in some countries, to turn back the epidemic, tobacco companies continue to develop new products to maintain their profits, often disguising these new products in a cloak of attractiveness and reduced harmfulness." In Egypt, for one particularly hard hit country, tobacco use is still increasing by the day. "What is even more worrying is that shisha as well as cigarette smoking is widespread across age groups and social classes." Nahla Imam, sociology and anthropology professor at the Academy of Arts, was equally concerned: "We are even exporting the trend. Egyptian me'assel (sweet tobacco used in shishas ) is popular all across the world. You can buy it tax- free in some major European airports. Tourists are taking shishas and me'assel home with them when they leave." Here too, presumably, the assumption is that it is not as bad as tobacco. But little is known about shisha smoking; and two recent studies conducted in collaboration with WHO are only just beginning to shed light on the practice. The first, the work of the Youth Association for Population and Development NGO, was sociologically oriented. According to association chairman Hisham El-Rouby, "we attempted to look into the increased prevalence of this form of tobacco use particularly in the younger age groups and among females, for whom the practice would have been unthinkable in the past." The second, produced by the Egyptian Ministry of Health's Smoking Prevention Research Institute (ESPRI) -- founded by Awad Tageddin, former minister of health and professor of chest diseases at Ain Shams University, in 2002 -- is a medical monograph on the hazards of shisha smoking, incorporating the history and composition of the implement, the types of tobacco smoked in it, a comparison with cigarette smoking and a summary of the factors involved in its use, from the risk of cardiovascular disease to behavioural patterns associated with it. The study made extensive use of a national survey on shisha use among various groups. According to Mustafa Kamal, principal investigator at ESPRI, "the aim was to provide scientific evidence to guide the national plan for tobacco prevention and control". The monograph is important, he believes, not only due to the information it provides but by virtue of its being the first of its kind: "The next step has a broader perspective. We will be reviewing all shisha -related research conducted in the Arab world in the hope of sharing experience." The sample figures -- believed to be representative -- show that in the 15- 35 age bracket, 46.6 per cent of shisha smokers start smoking before the age of 18; 83 per cent live in homes where family members smoked; 29.3 per cent of student smokers spend upward of 50 per cent of their allowance on the habit. Although one- third of those surveyed believe that smoking shisha has no harmful effects on health and 50.6 per cent believe that it is less harmful than cigarettes, 71.5 per cent felt that a shisha smoker would be more susceptible to trying drugs. Al-Awwa is appropriately distressed: "These are very alarming signs which could cause a shift in diseases caused by tobacco use to younger people, especially heart- related diseases, if not tackled in the right way." At 41, Omar (not his real name) is smoking shisha in an attempt to minimise exposure to tobacco smoke; starting with cigarettes, he had shifted to the pipe before settling finally on shisha : "Cigarettes are more handy. They are more easily accessible at home or outdoors. For a shisha smoker, on the other hand, things are not so easy. I need to get dressed and go out to a café to smoke it. Which is why I made that choice: to make smoking more difficult for me." This is all very well, but according to Tageddin, "the water pipe smoker can inhale an amount of smoke during one shisha session equivalent to what a cigarette smoker inhales consuming 100 or more cigarettes. Shisha is just as harmful as cigarettes." Likewise WHO literature, which stresses that "water pipe smokers [are] at risk for the same kinds of diseases as are caused by cigarette smoking, including cancer, heart disease, respiratory disease and adverse effects during pregnancy". Water pipe smoking has a few additional risks of its own: sharing a mouthpiece increases the risks of such communicable diseases as tuberculosis -- which is re-emerging in Egypt. "Even if the mouthpiece is changed for every user," Tageddin argues, "the humid, airtight hose can easily act as a source of infection." Sadly, the reasons behind the spread of shisha smoking are as complex as its medical profile. According to Imam, "for decades, shisha was thought to be less harmful and less addictive than cigarettes. It was more exclusively prevalent among older men, mainly in rural areas, and among the working classes, the lower socio- economic level. Nowadays it is also used by members of the higher socio-economic levels as well, including women -- a vertical movement of a social practice, to put it in technical terms. It's a two-way process in which the rich copy the poor because it's 'cool', while the poor copy the rich because they look up to their lives." The phenomenon spread particularly during the upsurge in the number of Egyptians working in the Gulf, she added, where the practice is far more usual as an aspect of daily life; both Egyptians who adopted the habit and tourists from those countries gave way to a larger, more upscale market. Mohamed Afifi, professor of modern and contemporary history, Cairo University, believes that if contact with the Gulf region had any role to play, it would be by bringing in more money and affluence. "The 1970s witnessed the introduction of the 'Open Door' policy. It was a time of radical historical and social transition. Drastic changes in the then prevailing values took place. In addition, groups that became more affluent moved from the lower to the upper sectors of the society carrying with them the culture and values that prevailed in the previous domain", he explained. Rather more alarming to Imam is the nonchalance with which young people's shisha consumption is tolerated: " Shisha smoking is not equated with cigarette smoking. It is even more appealing to youngsters. This is something that they can do and enjoy together, not only individually as is the case with cigarettes. An endless variety of flavours is at hand. Add to this their ignorance of the hazards it presents," and you end up with a scary prospect indeed. According to El-Rouby, it is interesting to note that the starting age for shisha smoking (15-20) is the age during which peer pressure is greatest. It is a group ceremony, he says, a way of being accepted and asserting yourself; even females reporting feeling more confident smoking shisha. As Al-Awwa points out, however, the problem is not easily resolved: neither anti-tobacco campaigns by the Ministry of Health -- often in collaboration with other ministries -- nor legal amendments impacting smokers, nor even religious verdicts from both Al-Azhar and the Coptic Orthodox Church have made tobacco any less socially acceptable: "People are consuming a lifestyle; sadly we have been unable to convince them of giving it up in favour of something more worthy. But this is what the tobacco industry is selling: a lifestyle. We are in dire need of better enforcement of existing laws: legislation may be crucial, but laws are never sufficient in themselves. Laws will only work when the public is convinced that they will be enforced." For her part Imam argues that up to the present smoking is still a matter of personal freedom: "In restaurants there are still smoking and non-smoking seating. People do not recognise anti-tobacco laws. You walk down the airport and you find officials who should be enforcing the law smoking underneath the no-smoking signs. How can the public be convinced?" Nor is the media free from blame. "There is a great dilemma on the official side," Al-Awwa explains. "On the one hand immense money and effort are pumped into anti- tobacco measures, yet many national television dramas, for example, are loaded with pro-tobacco messages. This undermines the credibility of intentions regarding tobacco control." In 2003, the Eastern Mediterranean Regional Office of the WHO issued a press release expressing concern about the overt use of tobacco, alcohol and drugs in Ramadan television serials: "[It] is unfortunate that the holy month of Ramadan -- the month of worship, righteous deeds during which all sins are supposedly avoided, is abused for the promotion of what harms people's health and poses a threat to their lives." That year the WNTD slogan was "Tobacco kills: it shouldn't be advertised, glamorised or subsidised". Two years later, in 2005, another press release entitled "A positive step on the way" praised the decline in the number of scenes containing tobacco on Ramadan TV and calling for similar measures regarding alcohol. Along the same lines, Imam explained, "the media can send out conflicting messages. Tobacco is featured as a means of taking the steam off and a way out of stressful situations. Drama shows glamorous stars smoking in different situations; in crisis they smoke, if in deep thought they smoke, if in a creative mood they smoke. We put deadly warnings on cigarette packages but then icons, intellectuals, and gallant heroes are all portrayed as smokers. This can be very confusing, particularly to young people. We need a single, clear and positive image." Hussein Geziary, WHO Regional Director for the Eastern Mediterranean, highlighted the media's role in the course of his speech for WNTD 2006: "We face now an extensive campaign of indirect advertising through the media, television, satellite channels and the Internet. This campaign is targeting young people, the main users of these different media. The media and the role models of society are those who convey the message, for it is they who are heard and listened to more than anybody else..." While anti-tobacco advocacy and awareness campaigns are important, Al-Awwa believes that governments should make an effort to regulate all types of tobacco and raise awareness of its deadly effects: "The familiar scene of young people sitting in cafés smoking shisha has to change for the sake of the well- being of future generations. This can only be accomplished by a coherent, consistent and harmonious package of joint actions including strong -- and promptly enforced -- legislation and widespread advocacy for health, well being and an altogether better tomorrow". In retrospect ONE OF the documents of the World Health Organisation encloses an interesting historical account of the roots of the waterpipe. According to that account, the device was invented in India by a physician during the reign of Emperor Akbar (1556-1605). Hakim Abul Fath, the physician, suggested that by passing tobacco smoke first through water, it would be rendered harmless. "Thus, a widespread but unsubstantiated belief held by many waterpipe users -- that the practice is relatively safe -- is as old as the waterpipe itself". In Egypt, smoking is closely linked to the Ottoman era. Mohamed Afifi, professor of modern and current history, Cairo University, told Al-Ahram Weekly that tobacco entered Egypt in the early 17th century first into the popular culture; in Sufi circles and similar closed circles before it became popular among the upper classes and the aristocracy. "At the time there was much debate whether tobacco was haram (religiously forbidden). It was therefore restricted to more discreet and popular circles before moving into the wider consumerist state including the aristocracy, women and the whole society. There was even some debate among physicians as to whether it was good or bad for health". Egyptians first used the shobok (a device similar to the pipe). "The shobok was much larger than the pipe and not very comfortable to use. We do not know when exactly the transition to the shisha occurred but we do know that by the 19th century it was common and was linked to popular street cafés. Later on with the advent of the cigarette and the cigar, the upper classes, influenced by Western values, preferred the new products and deserted the shisha to distinguish themselves from common people", Afifi said. "In fact, a whole set of shishas featuring the historical development of the device is on display at the Islamic Museum in Cairo for people to see."
