Waterpipe

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Background

What is waterpipe?

Waterpipe has different names in different countries such as narghileh, shisha, hookah, hubble-bubble, and bong.

The World Health Organization (WHO) defines waterpipe tobacco smoking (WTS) 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 Some countries have developed their own definition of WTS.2

The origin of WTS is somewhat unclear. In the late 19th century, it was popular among older men in the Middle East but with the introduction of sweetened and flavoured tobacco in the early 1990’s, WTS surged among youth, and expanded globally, through universities and schools.34

Social acceptability of WTS has increased, due to the growth of ‘café culture’ in the Middle East and globally, WTS in cafés , restaurants and bars has become the focus of social gatherings of young people, as a waterpipe can be shared by a group of friends over an extended time, with a slow puff rate. Tourists have taken WTS habit back to their countries, and expatriates from the Middle East have opened waterpipe cafés and restaurants around the world.1456In this way waterpipe has spread beyond the Middle East and become integrated into the global tobacco market.7 While there are restrictions on tobacco advertising in other regions, products have been promoted throughout the Middle East via satellite television, internet and social media. As these media are largely unregulated the industry is able to circumvent most advertising bans (see below for more on product regulation).561

Transnational tobacco company interests

Historically, transnational tobacco companies had little interest in WTS. A review of tobacco industry documents showed no focus on waterpipe tobacco or its accessories, except for some ‘waterpipe-inspired’ products that did not become mainstream in the market.8

This was the case until  2012, when Japan Tobacco International (JTI) acquired Egyptian company Al Nakhla.9 At the time Al Nakhla was globally the largest company manufacturing waterpipe tobacco products.10 However, even this was perceived as a strategy to enhance the sale of cigarettes.8

In 2019, Philip Morris International (PMI) filed a patent ‘Shisha device for heating a substrate without combustion.’8  However, as of 2023, this product had not yet appeared on the market.

  • See Waterpipe market below for details on companies, brands and market shares

Use

an image of waterpipe device and its components

Image 1: Waterpipe device (Source: Waterpipe Briefing, National Centre for Smoking Cessation and Training/Jawad et al 2013)1112

Waterpipe tobacco is smoked using a device like that in image 1. As the smoker draws from the mouthpiece, a piece of lit charcoal heats the waterpipe tobacco leaf within the head of the apparatus. This heat generates smoke that travels through the device’s body and enters the water-filled bowl. By inhaling through the hose attached to the top of the bowl, the smoker pulls the smoke through the water, resulting in bubbles, before finally inhaling the smoke via the mouthpiece. Typically, the head is filled with flavoured and sweetened tobacco, and it is separated from the charcoal by a perforated aluminium foil. While the specific design and characteristics may vary across different regions, the fundamental principle remains consistent: the smoke is filtered through water.5

E-hookahs or e-shisha or hookah pens are not waterpipe devices as they do not involve burning charcoal. These are classified as electronic nicotine devices, similar to e-cigarettes, where a sweetened liquid is electrically heated creating an aerosol to be inhaled.1

The role of flavour

Traditionally waterpipe tobacco (WT) uses unflavoured types of leaf (Ajami, Tumbak, or Jurak). However, since the 1990s flavoured tobacco has become more popular.561

The most common type of flavoured tobacco for WTS is Maasel (or Mo’assel), or ‘honeyed’ tobacco, which consists of one-third tobacco and two-thirds honey and fruit flavours, usually a combination of tobacco, molasses(the thick syrup from raw sugar), glycerine and fruit flavours.11 A study among adults in Lebanon indicated that the introduction of novel tobacco flavours contributed to people initiating WTS and increased its use.13 Similarly, a study from Iran indicated that the wide variety of “tempting” flavours  contributes to the increase in prevalence of WTS among youth and women. 14

In addition, a UK study found WTS is incorrectly perceived as safer than cigarette smoking “due to the pleasant odour [and] fruity flavours.”15

Health effects

Evidence shows that waterpipe, like other tobacco and nicotine products, is addictive.16

As with cigarettes and rolling tobacco, WTS is toxic and carcinogenic. One study identified 27 known or suspected carcinogens in waterpipe smoke.17 As a waterpipe is often shared, it is also a mode of transmission for communicable diseases, a particular concern during the COVID-19 pandemic.18 Consequently, WTS has both short-term and long-term harmful health impacts on users, and also harms those exposed to second-hand smoke.1192021

Among many groups of users there is a belief that waterpipe smoke is filtered in water, making it less harmful than cigarette smoking. 15 This perception has contributed to a growing popularity and acceptance.561

However, waterpipe contains similar or greater levels of toxic substances to cigarettes, leading to the same cellular effects as conventional products including pulmonary and arterial diseases.1722

Prevalence

A 2018 systematic review, which included 129 studies from 68 countries, found that WTS was highest among adults in the Eastern Mediterranean region (EMR). However, among youth, prevalence was similar in Europe and EMR. Comparing WTS between adults and youth, globally the study reveals that smoking is higher among youth.23

The WHO, published an Advisory note on WTS in 2015, indicating that although WTS was traditionally associated with the Eastern Mediterranean region, Southeast Asia and Northern Africa, WTS has begun growing globally among adults of both genders. In addition, WHO noted that WTS was rising particularly quickly among schoolchildren and university students.6

Africa

Research in South Africa from 2012, found that 20% of poor high-school students reported using waterpipe daily, and 60% reported ever having used one.24 A study in Western Cape from 2013, reported higher figures: 40% current use, and 70% ever use.25 Even among medical students, use may be relatively high; a study in Pretoria in 2010 found that nearly 20% of participants had used a waterpipe at some time.26

The Americas

Although there is limited research on waterpipe in Latin America, some has been conducted in the United States (US) and Canada. A national study of 18,866 US adolescents, published in 2014, reported that 7.3% have used waterpipes.27 In Canada, although cigarette smoking among young people had significantly decreased, waterpipe use increased by 2.6% among young people between 2006 and 2010.28

Eastern Mediterranean

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 in the region.29 It also increased in multiple countries, with prevalence ranging  9% in Oman to 16.2% in Kuwait.30

The public representation of the WT industry primarily revolves around the hospitality sector (waterpipe cafes, bars, and restaurants).31 Products are promoted online by users via social media, rather than WT companies.31  A study from Lebanon indicates that, following the passage of the tobacco control law, enforcement of a ban on indoor smoking came to a halt due to the lobbying of policy makers by establishments where waterpipes were available.32

In 2012, the hospitality sector in Lebanon commissioned Ernst & Young (now EY) to evaluate the effects of the smoke-free law on their financial revenue and impact on employment.3133

Europe

In 2012 a report showed that, 16% Europeans aged 15 years or over, had tried waterpipe at least once.34 Reported prevalence of  WTS ranged from 35-40% in Latvia, Estonia, and Lithuania, but was below 10% in Malta, Spain, Portugal, and Ireland.34 Use was growing sharply in Austria, the Czech Republic and Luxembourg.34 In England, data from a report in 2013 indicated that youth (aged 16-18) WTS was low, at 3%.35

However, a study looking at adult smoking in England using a single point in time nationally representative survey found that non-cigarette smoking (pipe, cigar and waterpipe) increased 5 times from 2013 to 2023 – from around 150,000 to over 770,000 users. 36 Cigars were the most used of the three product types, closely followed by waterpipes, and the increase was higher among young adults.36

South-East Asia

Studies (2008 – 2011) suggest that WTS 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,  Indonesia, and Thailand.3738 A study from the South-East Asian Region indicates a noticeable increase in the waterpipe bars and restaurants. They mainly host young individuals.39

Western Pacific

Waterpipes in the Western Pacific are called “bongs” and are different in design from the popular Middle Eastern waterpipes, and therefore are often not included in waterpipe studies. Bongs can be made of bamboo, metal or glass and are used in China, the Lao People’s Democratic Republic, Myanmar, and Vietnam. In 2010 in Vietnam around 13% of males aged or over 15 used bong.37

Regulations

In many higher income countries, waterpipe products are exempt from tobacco control policies. In many lower income countries, even if there is a policy, enforcement is very weak. Although flavouring is a major factor in the appeal to young people, flavour bans often do not cover waterpipe tobacco products. Consequently, WTS has increased globally, largely unchecked.5614

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”.40 This definition covers waterpipe tobacco products. WHO FCTC issued COP decisions specifically for waterpipe tobacco control:

  • At COP3 in 2008, Parties were invited to consider introducing health warnings and messages on tobacco packaging, including waterpipe packaging, and to use innovative measures requiring health warnings and messages to be printed on instruments used for waterpipe smoking.41
  • 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.42
  • At COP7 in 2016, more detailed instructions were given to Parties, including to ban the use of flavourings in waterpipe tobacco products.43
  • 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.44

The full list of articles covering waterpipe are listed in the Fact sheet: Waterpipe tobacco smoking & health.1

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 WTS, in particular with respect to education, research, and the dissemination of information that contributes to the implementation of the Convention.45

In 2018, the WTS knowledge hub submitted a report to the WHO FCTC COP8 that summarized Parties’ regulations concerning waterpipe use.46 This report was updated in 2022, and found that, of the 90 countries reviewed, over half (47) had policies relating to waterpipe use.2 The majority of policies, nearly 45%, were in Europe and around 21% in EMR.2

For up-to-date information on tobacco regulation, see the Tobacco Control Laws website, published by the Campaign for Tobacco Free Kids (CTFK).
Information on progress by parties can be found in the FCTC Implementation database.

During the COVID-19 pandemic in 2020, many countries temporarily banned the use of waterpipe as part of their efforts to stop the spread of the infection.18 In EMR alone, 17 countries banned waterpipe tobacco use in public places.47

Waterpipes, along with heated tobacco products, had been exempted from the EU flavour ban, stipulated by the 2014 European Tobacco Products Directive (TPD) and implemented in 2020.48 A new directive was issued in 2022 and came into force in 2023. This removed the exemption, bringing regulation of these products in line with cigarettes and hand rolled tobacco.48 49 This means that waterpipe tobacco with a “characterising flavour” can no longer be sold legally in the EU. For more information see Menthol Cigarettes: Industry Interference in the EU and UK.

Waterpipe Market

Advocacy group ‘It’s Still Tobacco’ estimated 54% to 69% of the global waterpipe tobacco products were sold in the Middle East and Africa (MENA), between 2016-2017.31

Market analysis company Valuate also estimates that the global waterpipe tobacco products’ market is still concentrated in the Middle East and Africa.50  They state that the next largest market share is held by Europe.50 Valuate estimated that the global waterpipe tobacco products market in 2022 was worth over US$800 million and forecasts the market to nearly double by 2029.50

Market research company Euromonitor International only estimates waterpipe product sales as part of a broader pipe tobacco category.51 It is therefore hard to estimate global market shares specifically for waterpipe tobacco. However, it is possible to identify specific waterpipe brands in the data. In 2022, JTI held the largest share with Al Nakhla, making up nearly 13% of the entire pipe tobacco market, followed by Al Fakher and Eastern brands (including Moassel) at around 12% and 8% respectively.51

Tobacco Industry Interference

The waterpipe industry is multidimensional, composed of both tobacco and non-tobacco actors, including third parties (or independent companies contributing to the tobacco supply chain). Interference can therefore be less obvious, making it difficult to develop effective WTS policy.52 However, there is some evidence of the tactics used by the industry and its allies.

Tobacco industry tactics used to interfere with and undermine regulation relating to waterpipe include:

Corporate social responsibility

Tobacco companies use Corporate Social Responsibility campaigns to improve their public image and gain access to influential policymakers. For example in 2024, JTI Egypt (the manufacturer of Al Nakhla) received a visit from the Japanese Ambassador to Egypt to celebrate the company’s project to empower women.53

Spreading misleading information

Waterpipe companies have published misleading information, including on the risks of tobacco products.

A study assessing the website of 18 company indicated that 12 of the websites published misleading marketing information.31  This was mostly prominent among non-MENA companies that had 8 websites compared to 4 MENA companies’ websites.31 Several companies in Jordan (Al-Rayan, Al-Tawareg, Al-Waha, and Mazaya) were found to have disseminated misleading information on the quality and safety of WTS.31 WTS charcoal industry also  published misleading information about charcoal being safe  referring to them as  them “environmentally friendly”, ‘free of chemicals’ ‘100% natural’ and.31

Another study looking at marketing materials at a European trade fair, and from the MENA region, found the prevailing message was that waterpipe use is less risky than cigarette smoking.54

Industry science

Al Fakher Tobacco Trading LLC, the second largest WT company, has a ‘shisha science’ section on its website and publishes its own research.55 A poster of a study published on its page indicates that the paper was presented at the CORESTA Smoke Technology Conference, in 2019. The study argues that a comparisons of Total Particulate Matter (TPM) yields between waterpipe and cigarettes do not provide meaningful information to inform an assessment of relative risk of its products.55

For information on science websites of transnational tobacco companies, see:

Illicit Trade

Although cigarettes form most of the illicit tobacco trade, there is some evidence of illicit trade relating to waterpipe use, specifically in the Eastern Mediterranean and South-East Asian regions.311.

Research from Turkey indicates that the majority (up to 99%) of waterpipe tobacco is illicitly traded, reflecting the significance of the informal economy in the waterpipe tobacco market.56 The illicit products are from both unauthorized domestic production, and increasingly tobacco smuggled from other countries, reported to taste better than locally manufactured products.57

OLAF, the European anti-fraud office, has identified suspicious shipments of waterpipe tobacco heading into Europe. In 2022, OLAF detected a truck carrying 20,000 kg of waterpipe tobacco as it was leaving Türkiye on its way to Denmark.58

Tax Evasion

There have been some documented cases of the under reporting of imports and exports of waterpipe tobacco, in order to evade tax.

In 2022, New Zealand changed its taxation law related to WTS to base it on product weight rather than the content declared by importers, as the customs authority suspected that some importers had been under-declaring tobacco content in order to avoid paying tax. 59

In 2023, the Mozambique the tax authority seized two containers of waterpipe tobacco, reporting the lack of a proper declaration for taxes and other customs fees.60

Relevant Links

TobaccoTactics Resources

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References

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