‘hubble-bubble leads to trouble’ – waterpipe smoking and oral health

How a waterpipe works

Although there are various types of waterpipes, differing in size, shape and colour, the typical layout is shown in Figure 1. The tobacco bowl is positioned within the body and is the site where tumbac (moistened raw tobacco) is covered with burning charcoal and placed on an ashtray on top of the pipe. This, in turn, is connected to a glass or steel decanter-shaped base containing liquids, usually water but sometimes water mixed with other liquids such as wine. The use of tobacco flavoured with molasses creates a mixture referred to as tobamel (tobacco plus ‘mel’ for ‘honey’ in Latin) or mu'essel (‘honeyed’, in Arabic). The tobacco bowl may be covered with a conical cap to allow use for a longer period of time in an open space.

The flavoured tobacco is indirectly heated using burning embers or charcoal. On sucking, tobacco smoke is drawn through the water, as it passes the stem (body) of the waterpipe undergoing a process of filtration. This is then drawn into the oral cavity via the hose(s) and mouthpiece(s), to produce smoke either to be inhaled or blown away.7^,8^,9^,10

How common is waterpipe smoking?

The highest prevalence of waterpipe smoking is in the Arabian Peninsula and the Middle East.7 In Syria, Lebanon and Egypt, 30% of adults reported using a waterpipe.4^,6 A Lebanese survey reported waterpipe smoking rates of 25% among pregnant women and 32% amongst university students, with no differences between socioeconomic groups detected.3 Also in Lebanon, a Global Youth Tobacco Survey (GYTS) reported that 34% of schoolchildren were waterpipe smokers, surpassing the number of youth cigarette smokers in that country.11 Other areas where waterpipe smoking is widely practised include India, Bangladesh, Turkey and China.3

However, waterpipe smoking is now a global phenomenon with use noted in Brazil, Canada, Germany, Korea, Ukraine, United Kingdom and the United States.5^,12

Evidence of this is the appearance of waterpipe cafes and ‘hookah bars’ in Europe and North America. The exact prevalence of waterpipe use in Western countries is uncertain, but at one British university, 38% (355/937) of students had tried smoking a waterpipe and 8% claimed to be regular users.5

It is therefore highly likely that general dental practitioners will encounter regular waterpipe smokers in the course of their everyday clinical work.

Why has waterpipe smoking become increasingly common?

Many reasons have been cited for the increasing use of waterpipes. In the UK, changes in the ethno-demographic make-up of the population is one likely factor, particularly in large conurbations and in universities. While solitary use is quite common, waterpipe smoking is predominantly a social phenomenon practised in groups among friends and family, in dormitories, dedicated cafes, restaurants and bars.3^,6 Also known as ‘shisha bars’, in the United Kingdom these establishments are particularly popular with young people from ethnic minority groups who use them as an alternative to visiting pubs and nightclubs.13 Indeed, such is their popularity that Local Government Regulation in England has had to issue supplementary guidance to its regulatory officers on the appropriate enforcement of the smoking ban in ‘shisha bars’.14

A further factor in the spread and acceptability of waterpipe use is that it is widely perceived as being safer, cleaner and less addictive than cigarette smoking.14^,15^,16 As the tobacco is heated indirectly from the waterpipe device and the resulting smoke is filtered through a column of water before being inhaled through the mouth using a pipe, many users assume, incorrectly, that these unique features of a waterpipe serve to minimize the adverse tobacco effects.17

Maassel, tobacco that is fermented in molasses and fruit essences, renders the tobacco soft and pliable, making it easier to use for waterpipes than other forms of tobacco. It produces smoke with a pleasant taste and aroma.4^,6^,12 Use by females is attributed to the lesser stigma associated with waterpipe smoking than with cigarette smoking.3 Indeed, it has been suggested that powerful anti-cigarette smoking campaigns have had a backlash effect, pushing cigarette smokers to other forms of tobacco use, including waterpipe smoking.18 Another reason for the increasing use of waterpipes may relate to economics. Waterpipe practice is thought to precede the use, or even substitute the use of, cigarettes, as it is cheaper.7

Finally, waterpipes may be used to facilitate the consumption of drugs other than tobacco, such as cannabis (marijuana).

Waterpipe smoking compared with cigarette smoking

There is a perception amongst many waterpipe smokers that there are fewer health risks when compared to cigarette smoking. In a cross-over experiment in which smokers who used both cigarettes and waterpipes were compared directly for toxicant exposure, Eissenberg and Shihadeh,19 demonstrated that, relative to cigarette smoking, waterpipe users experienced greater carbon monoxide (23.9 ppm vs 2.7 ppm), carboxyhaemoglobin (3.9% vs 1.3%) and similar nicotine levels (10.2 ng/ml vs 10.6 ng ml). These data were taken after a maximum of 45 minutes waterpipe use vs smoking a single cigarette. The exact exposure to tobacco smoke and its constituent toxicants depends on the ‘puff topography’, ie the degree and duration of inhalation and duration of use.19 This may be exacerbated by the less irritant nature of moisturized tobacco smoke compared with cigarettes and the extended duration over which a waterpipe session may take place.

However, the harm from waterpipe smoking does not solely relate to inhalation of the tobacco smoke by the smoker. In addition to the direct effects of imbibing/inhaling waterpipe smoke, smoke arising from the burning charcoal also has the potential to elevate atmospheric carbon monoxide levels and so there is a second-hand or ‘passive’ smoking effect of both tobacco and charcoal to those in the presence of an active waterpipe.

The evidence is therefore that smoking a waterpipe is as harmful to health as cigarette smoking.

Health and oral health effects of waterpipe smoking

Waterpipe smoking has not been studied nearly as extensively as cigarette smoking. Akl et al17 undertook a systematic review of the effects of waterpipe smoking on health. They concluded that, overall, the quality of studies on the deleterious effects of waterpipe smoking was poor and that better designed studies were required to identify the impact of waterpipe smoking on health fully. However, from the 24 studies included in their review they concluded that waterpipe smoking was significantly associated with lung cancer (OR = 2.12), respiratory illness (OR = 2.3), low birth weight (OR = 2.12) and periodontal disease (OR = 3 to 5). Increased ‘Odds Ratios’ were also observed for nasopharyngeal cancer, oesophageal cancer, oral dysplasia and infertility and, while not statistically significant, the confidence intervals did not rule out important associations.

Whilst the full extent of the impact of waterpipe smoking on oral cancer awaits determination, a number of putative aetiological mechanisms, which may act singly or synergistically, have been discussed.7^,20^,21 These include exposure to carcinogenic chemicals from the tobacco smoke condensates, mechanical trauma and irritation by the bamboo or plastic tubes used in the mouthpiece, heat generated from the smoke, and the possible contagious chronic infections associated with the use of one waterpipe by several individuals. Furthermore, the irritation from tobacco juice is likely to be greater, as it is practised for a longer duration of time than other smoking habits.^4.7,20 However, Chaouachi18 has argued that no ‘tobacco juice’ can penetrate and reach the smoker's mouth, because the inhaled waterpipe smoke temperature is below that of ambient air, unlike in cigarettes, pipes or cigars.

A further possible risk of waterpipe use is the transmission of infection due to sharing of a common mouthpiece – a risk not usually encountered in smoking cigarettes. There is therefore the need for further work in this area.

What is clear is that smoke from a waterpipe contains the addictive drug nicotine and, as is the case with other forms of tobacco consumption, more frequent use is likely to be associated with reports of addiction.

The view of the World Health Organization

In 2005, the World Health Organization issued an advisory note on the health effects, research needs and actions required by regulators in response to the global spread of waterpipe use.10 This provided a very useful summary of the science around waterpipe smoking. The conclusions of that report are summarized in Table 1.

Interventions for waterpipe smoking cessation

Given the potentially lethal effects of waterpipe smoking, it is important that users are informed of the dangers and, where appropriate, offered assistance to stop their use. However, a recent Cochrane review on interventions for waterpipe smoking cessation concluded that there were no completed intervention trials targeting waterpipe smoking cessation.22

The role of the dental team in assisting patients to stop smoking is now well recognized23 and national guidance has been issued on this topic.24 Most members of the dental team are by now aware of the ‘ask, advise, assess, assist and arrange follow-up’ mantra as it applies to cigarette smokers. As this article has highlighted, it is likely that the dental team are likely to encounter waterpipe users. Given the general conception of many users that waterpipe smoking is less harmful than other forms of tobacco use, it is important that all healthcare professionals are in a position to correct this misunderstanding. Ethnic and cultural barriers may form a hindrance to discussing waterpipe use, to a greater degree than for cigarette smoking. However, appropriately informed, there are good reasons for dentists and dental care professionals to raise the topic and discuss the impact of waterpipe use on oral and general health. We would suggest that the basic principles underlying tobacco counselling in general apply equally to waterpipes. Referral to the local smoking cessation service for those who express an interest in stopping, or who are concerned about their waterpipe use, is as important as for cigarette, pipe and cigar smokers.

Conclusions

Waterpipe smoking is becoming increasingly common. Although many users believe that this constitutes a safer form of tobacco use than smoking cigarettes, they are mistaken. The dental team should be aware that using a waterpipe to smoke tobacco poses a serious hazard to smokers and to others exposed to the smoke emitted. Oral signs, such as halitosis, tooth-staining, periodontal disease or mucosal pathology can all act as triggers to discussing the impact of tobacco use on oral health, irrespective of the mode of consumption, including via a waterpipe. Referral to the local smoking cessation service should be considered for all those who express an interest in help with a waterpipe smoking habit.