The Rise of Shisha and The Fall of Ghanaian Youth: An Emerging Deadly Trend

For eons tobacco plant (Nicotiana) has been used as remedy for several maladies, and as a sociocultural relic because of its pleasurable effects. There are over 60 species of tobacco plant. For decades, Nicotiana tobacum has been the most commercially cultivated of the tobacco plant species. The name, tobacco, is a misnomer. The pipe that was used by the indigenous peoples in the New World to smoke was called tobaco or tavaco; and the herb that was smoked was called petum (also known as betum, cogioba, cohobba, quauhyetl, picietl or yietl). However, in this essay the term tobacco will be used according to modern meaning. In the 15th century, Christopher Columbus with his team of explorers found out that the indigenous peoples in the New World smoked petum for therapeutic and other purposes. The explorers then transported tobacco to Europe to spread the news about its therapeutic effects. Tobacco became known as the ‘holy herb’ and ‘God’s remedy’ because of the mass acceptance of its effects. Both medical and lay communities in Europe bought into the publicised therapeutic effects, to the extent that in 1665, during the plague in London, children were allowed to smoke tobacco in classrooms. Despite the popular perception that tobacco was safe and had several therapeutic effects, in 1602, some doctors begun to question the accepted narrative. By 1828, nicotine, an active constituent of tobacco was identified and underwent several experimentations. From then, the medical community became more doubtful of tobacco as being safe, and even as a treatment option. By the 20th century, the negative effects of tobacco were coming to light, and the perception of its therapeutic uses were also fizzling out, though others remained enthusiasts of tobacco as God’s remedy (Ba, 2004).

Tobacco-use is the single most preventable cause of morbidity and mortality (Akl et al., 2011; Ashiamah, 2016; Logo et al., 2021; Waziry et al., 2017). Its use poses great public health threat to society. It kills over 8 million people each year. These deaths consist of both direct users (over 7 million), and second-hand smokers (about 1.2 million). Second-hand smokers are persons who do not directly smoke tobacco but are rather exposed to the smoke due to their nearness to persons who are directly smoking (Dadipoor et al., 2019; Logo et al., 2020; Parimah et al., 2022). Tobacco can be processed and used in different ways. It can be smoked as cigarette (combustible or electronic), cigar, waterpipe (also known as shisha, hookah, goza or nargileh), bidis and snuff. It can also be chewed (Al-Sawalha et al., 2019; Logo et al., 2020, 2021). Tobacco contains over 7000 compounds, of which about 70 are known to be associated with cancers. Other constituents are known to be associated with male infertility, diseases of the heart, low birth weight, and others (Al-Sawalha et al., 2019; Awan et al., 2017; Mamtani et al., 2017; Omolaoye et al., 2022; Waziry et al., 2017). Though tobacco has been associated with several preventable diseases and deaths, conflict of interests amongst stakeholders and regulators have contributed to hindering adequate regulation across the globe (Bekelman et al., 2003; Wells, 2017). The focus of this essay is to discuss waterpipe tobacco smoking (WTS) or waterpipe smoking (WPS), one of the ways of tobacco-use. World Health Organization has described it as an emerging deadly trend (Akl et al., 2011).

Shisha, also known as hookah or waterpipe, is another form of combustible smoking of tobacco, where flavoured tobacco is burned with charcoal, and then the smoke is guided through water via tube before it is inhaled by the smoker. The waterpipe apparatus is made up of different parts: head (contains charcoal and tobacco), body (guides the smoke into the water), bowl (contains water), hose/pipe, and mouthpiece (Akl et al., 2011; Dadipoor et al., 2019; Shihadeh et al., 2015). The intention behind the passage of tobacco smoke through water is to filter the smoke to make it safer. Also, the added flavour, mostly fruity, is to enhance the packaging and improve desirability. In fact, the water filtration has created a misconception that waterpipe tobacco smoking is safe, and the flavouring of the tobacco smoke has made it more attractive, especially to children and women (Al-Sawalha et al., 2019; Dadipoor et al., 2019; Kadhum et al., 2015). Waterpipe tobacco smoking was invented in ancient India, and it has remained traditional to the Middle East, and a common practice for hundreds of years (Akl et al., 2011; Logo et al., 2020; Mamtani et al., 2017). Currently, there is a worldwide prevalence of this practice (Parimah et al., 2022). Globally, about 100 million people smoke shisha daily, and most of these are adolescents, high school students, and university students (Akl et al., 2011; Al-Sawalha et al., 2019; Awan et al., 2017; Mamtani et al., 2017; Waziry et al., 2017). WPS is also making inroads in Africa, and the continent is seen as being at early stages of a tobacco epidemic (Logo et al., 2020, 2021). There is a paucity of data on waterpipe tobacco smoking in Ghana, however, some academics have conducted some research to throw some light on this dark space. An analysis of Global Youth Tobacco Survey (GYTS) 2017 revealed that amongst Junior High School students aged 13 years to 15 years, waterpipe smoking was common amongst female students. There was a growing acceptance amongst the youth; and there was an emerging tobacco-use epidemic in the country, especially amongst the youth and students (Logo et al., 2020). Furthermore, another study revealed that there was a significant association between shisha and deviant behaviour amongst high school students in Ghana (Parimah et al., 2022). In fact, another study revealed that age, exposure to shisha, and magnitude of pocket money were noticed to be associated with hookah-use (Logo et al., 2021). It is interesting to note that another study conducted in Accra revealed that several people who had smoked shisha were attracted to it by the flavoured smell and taste, and the fashionable nature of the practice (Ashiamah, 2016). It was found that marijuana was sometimes added to the tobacco that was used in shisha (Ashiamah, 2016); and this (marijuana and tobacco combination) also had a significant and synergistic association with deviant behaviour (Parimah et al., 2022). The emergence, rising and prevalence of waterpipe tobacco smoking in Ghana point to a failed public health system (Logo et al., 2020).

Waterpipe tobacco smoking has been thought to be a safe use of tobacco, but recent data posit otherwise. It is associated with lung cancer, head and neck cancers, male infertility, atherosclerosis, metabolic syndrome, and others (Akl et al., 2011; Ashiamah, 2016; Awan et al., 2017; Logo et al., 2020; Mamtani et al., 2017). In fact, even waterpipe smoking without tobacco is associated with all WPS-related diseases and deaths except nicotine-related ones (Shihadeh et al., 2015). Interestingly, in Malaysia, a significant proportion of university students, including medical students, who participated in a study believed that shisha was safe and contained neither tobacco nor nicotine (AL-Naggar & Saghir, 2011; Kadhum et al., 2015). WTS contains similar toxicants present in cigarette smoking. In addition to this, the inclusion of charcoal in the combustion of tobacco in shisha adds by-products of charcoal to the inhaled waterpipe tobacco smoke. Hence, in total, shisha smoke contains toxicants from tobacco, charcoal and the flavouring agents used. There are over 300 chemicals present in waterpipe tobacco smoke, with 69 cancer causing agents and 82 toxicants, including tar, nicotine, carbon monoxide, and heavy metals (Shihadeh et al., 2015). Nicotine is the addictive ingredient in tobacco. It has been shown to lead to male infertility through disruption of reproductive system-related hormones, weakening of sperms, damage to sperm DNA, reduction/increase in number of chromosomes, and ultimately damage to the testes (Al-Sawalha et al., 2019; Omolaoye et al., 2022). In fact, the impact of shisha smoke on male fertility has been shown to even occur when a male foetus is exposed when in the womb (Al-Sawalha et al., 2019). Other studies have found shisha to damage the lung, leading to chronic obstructive pulmonary disease (COPD) (Waziry et al., 2017). Carbon monoxide poisoning is lethal. In Ghana it has been reported to have caused death of families that slept with burning coal in their rooms, which was an attempt to keep warm during rainy nights (Hawe, 1963). These diseases and deaths associated with waterpipe smoking are not limited to only direct smokers, but also second-hand smokers (Shihadeh et al., 2015). This is very important as waterpipe tobacco smoking is done both at homes and in public places. Unlike cigarette, the structure and size of waterpipe make it difficult for it to be carried around when one is smoking, thus shisha is likely to be smoked in the presence of others who may not be directly or interested in smoking. In Ghana, some teenagers who had ever smoked waterpipe, and some of those who had ever been exposed to it, both experienced it at home (Logo et al., 2020).

Despite the numerous negative effects of waterpipe tobacco smoking, there is a rise in the practice in Ghana, Africa and across the globe. Factors accounting for the rise in waterpipe smoking are the perception that shisha is safe; cheaper cost compared to cigarette, which has been taxed as part of public health regulations; and the sociocultural role shisha has come to play in social gatherings (Dadipoor et al., 2019; Mamtani et al., 2017). In addition to these factors, shisha is perceived as non-addictive, and existing laws do not adequately regulate this emerging practice (Dadipoor et al., 2019; Jawad et al., 2015). With regards to laws, globally, countries that use generic tobacco-related laws that do not specifically name waterpipe tobacco smoking, and accordingly regulate it have been found not to be sensitive to the uniqueness of this emerging practice (Jawad et al., 2015). Ghana is one of these countries. The Public Health Act, 2012 (Act 851) has provisions dedicated to regulating tobacco and tobacco products. Shisha is a tobacco product; hence, it can be assumed that the framers of Act 851 captured it by using the term tobacco product in the law. However, the absence of the term, waterpipe tobacco smoking (shisha, hookah, and others), places our law under the group of laws across the globe that inadequately regulate this emerging trend. The rising hookah-use amongst the Ghanaian youth, testifies that the regulation is non-sensitive and inadequate. For example, Section 62 of the Public Health Act, 2012 of the Republic of Ghana states that: (2) A person shall not package and label a tobacco product in a manner that seeks to promote the tobacco product in false, misleading or deceptive way or is likely to create an erroneous impression about its characteristics, health effects, hazard or emissions (Public Health Act, 2012 (Act 851), 2012).

Waterpipe, a tobacco product, in its nature is packaged with water filtration component and flavoured smell and taste; in such a way that creates the erroneous impression of safety and desirability. The current state of the Public Health Act precludes waterpipe tobacco smoking yet allows cigarette smoking under certain circumstances and limitations. This oxymoronic feature of the law needs to be addressed in such a way that waterpipe tobacco smoking will be specifically captured in the laws and then adequately regulated. Boxes containing cigarette are labelled with health warnings, and this is in line with the law. Waterpipe on the other hand do not come in boxes, hence, health warning labels are difficult to inscribe legibly. As it stands, vendors of waterpipe tobacco smoking do not display any kind of health warnings. There is a need to legislate a specific provision for shisha that will require that vendors, for example, have large and bold posters at the smoking sites, or waterpipe should be served with health warning leaflets. Currently, waterpipe tobacco smoking is done in public and closed places, which the Public Health Act even abhors. There is a need to specifically legislate the allowable sites for waterpipe smoking. Furthermore, there is an urgent need for public education on the health implications of shisha, a tobacco product. This responsibility has been placed on the doorstep of some named state institutions in the Public Health Act. Section 66 of the Act stipulates that:

1. The Minister shall ensure that the Ministry embarks on public education on the effects of tobacco use.

2. The Minister shall ensure that each health facility has a unit or department that provides education against smoking.

3. The Minister in collaboration with the Minister responsible for Education, Youth and Sports, the National Commission for Civic Education and other related agencies shall incorporate education against smoking in their programmes.

4. The Minister responsible for education shall incorporate education on tobacco in the school health programme and other relevant programmes to provide formal education on the dangers of smoking to discourage the youth from tobacco use (Public Health Act, 2012 (Act 851), 2012).

Controlling waterpipe tobacco smoking, an emerging epidemic, requires concerted effort from scientists, healthcare professionals, public health officials, health educators and legislators (Mamtani et al., 2017). Studies conducted in Ghana reveal that some youth who use shisha have attempted stopping but failed. This points towards a possible substance-use disorder, which requires the intervention of psychiatrists and clinical psychologists. Some young users of shisha also explain that they were not denied access to waterpipe even though they were underage. There is an urgent need to educate the public, and specifically legislate the tobacco and tobacco product space in such a way to be sensitive to emerging tobacco products.

In conclusion, waterpipe tobacco smoking is associated with several disease conditions and preventable deaths. It is an emerging deadly trend amongst Ghanaian and African youth. There is an urgent need to uproot and not sharpen the proverbial tree stump that has the potential of causing harm.

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