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- Sebastian ThomasPublished on: 13 May 2016
- FOUAD A. AL-BELASYPublished on: 13 May 2016
- FOUAD A. AL-BELASYPublished on: 13 May 2016
- Kamal ChaouachiPublished on: 13 May 2016
- Kamal ChaouachiPublished on: 13 May 2016
- Wasim MaziakPublished on: 13 May 2016
- FOUAD A. AL-BELASYPublished on: 13 May 2016
- Fouad A. Al-BelasyPublished on: 13 May 2016
- Kamal ChaouachiPublished on: 13 May 2016
- Published on: 13 May 2016Waterpipe and not Shisha should be the unifying term
- Sebastian Thomas, Lecturer,Dental School
Show MoreDear editor,
I beg to differ with the statement “Shisha –this word is used everywhere in the world” {e-letter- Shisha vs. “Water-pipe” : The Question of a Unifying Term(Kamal Chaouachi)}
The word Shisha is not used everywhere in the world. If it is used, the meaning is different. In the Indian subcontinent, a region where hundreds of languages are spoken, the word connoting any type of waterpipe is ‘...
Show LessDear editor,
I beg to differ with the statement “Shisha –this word is used everywhere in the world” {e-letter- Shisha vs. “Water-pipe” : The Question of a Unifying Term(Kamal Chaouachi)}
The word Shisha is not used everywhere in the world. If it is used, the meaning is different. In the Indian subcontinent, a region where hundreds of languages are spoken, the word connoting any type of waterpipe is ‘hookah’. Of course, Hindi and few other languages have shisha in their vocabulary, but it refers to ‘glass’ or ‘mirror’ not to any kind of smoking.
The terms Hookah, Narghile and Shisha are never obsolete or redundant and should be employed in the propagation of the research results among the waterpipe smoking laypeople. But the research community’s need for a unifying term should not be debatable and waterpipe seems to be the most appropriate, till a better term is evolved.
Till then, I am sure the researchers involved will have the discretion to differentiate waterpipe with the household plumbing equipment terminology just like ‘AIDS’ is differently comprehended from ‘aids’- '3rd person present singular' of the word ‘aid’.
Conflict of Interest:
None declared. - Published on: 13 May 2016CORRECTION
- FOUAD A. AL-BELASY, Professor of Oral Surgery and Vice Dean
The eletter entitled "A Personal Experience with Goza and Shisha Smoking is authored by only FOUAD A. Al-BELASY. The names of other co- workers were mistakenly entered during submission from below the bar displaying how to enter other colleagues.
Conflict of Interest:
None declared. - Published on: 13 May 2016The Issue of Nomenclature: In Reply
- FOUAD A. AL-BELASY, Professor of Oral Surgery and Vice Dean
Show MoreDear Editor,
This is to comment on the following recently published eletter:
The issue of nomenclature: Wasim Maziak (17 June 2006)
In a dictionary search for Hookah, Hubble-bubble, Narghile, Arghile, Water-pipe and Shisha, the Oxford Paperback Dictionary [1] defines Hookah as an oriental tobacco pipe with a long tube passing through a glass container that cools the smoke as it is drawn thr...
Show LessDear Editor,
This is to comment on the following recently published eletter:
The issue of nomenclature: Wasim Maziak (17 June 2006)
In a dictionary search for Hookah, Hubble-bubble, Narghile, Arghile, Water-pipe and Shisha, the Oxford Paperback Dictionary [1] defines Hookah as an oriental tobacco pipe with a long tube passing through a glass container that cools the smoke as it is drawn through and defines Hubble- bubble as (i) a simple Hookah, (ii) a bubbling sound and (iii) a confused talk. No definition was given in this Oxford dictionary to Narghile, Arghile, Shisha or Water-pipe. Al-Mawrid [2] defines Hookah into its literal meaning as well as Narghile and Shisha (the Arabic word). It defines Water-pipe as (i) a water tube and (ii) Narghile and gives the term Narghile its literal meaning. Al-Mawrid also gives no definition to Arghile or Shisha. In this context, the term Hookah dominates. Therefore, the conclusion that the term Water-pipe has the strength of highlighting a unique and unifying feature of all other local types [3] has to be reconsidered.
It is the scientific literature as well as Media which paves the way for the publicity of scientific terms. In this respect, one can review the deep effect of Media on the widespread use of scientific terms (acronyms) such as AIDS and SARS to the extent of publicity despite the specificity of both terms and the deficient knowledge of the public. Therefore, with the international use of Shisha as well as benefiting the deep effect of Media, the term Shisha, in my opinion, will be more appropriate for the scientific literature increasing the potential of sharing and communicating research results [3].
It is interesting to say that in the search for the definition of Shisha, the term Shish-kebab was found in both dictionaries and I believe that the habit of Shisha smoking is of no less significance than the habit of eating Shish-kebab.
References: 1- Liebeck H, Pollard E: The Oxford Paperback Dictionary. Oxford University Press 1994. 2- Ba'albaki M: Al-Mawrid: A Basic Modern English-Arabic Dictionary. Beirut- Lebanon 2002. 3- Maziak W: Eletter: The issue of nomenclature. TC online 17 June 2006.
Conflict of Interest:
None declared. - Published on: 13 May 2016Shisha vs. “Water-pipe” : The Question of a Unifying Term
- Kamal Chaouachi, Researcher in Socio-Anthropology and Tobaccology
Show MoreShisha vs. “Water-pipe” : The Question of a Unifying Term
...Show LessShisha vs. “Water-pipe” : The Question of a Unifying Term
Hookah, Narghile and Shisha are definitely not “local words” (Maziak). “Hookah” is used (with slight spelling variations) in India, Pakistan, the USA, Canada and many English speaking countries. “Narghile”, with the same reservations, is prevalent in many countries of the Middle East, including Turkey, where it is the official name (“nargile” with no “h”), and Iran where it is one of both national forms with the Qalyân. “Narghile” is also used in many European and African languages. As for “Shisha”, it has been a word widely employed in Asia and Africa for centuries. Today, its related service (within the so-called “shisha bars”, “shisha lounges”, etc.) is offered in almost all countries of the world.
By contrast, I am afraid the word “water-pipe” lacks the necessary essence in a field where the socio-cultural context is known to be complex and highly important in relation to biology and psychopharmacology. So, I would encourage my colleagues to keep it exclusively for experiments on smoking machines in a laboratory and never use it for real human smoking. Another problem with “water-pipe” is its strong connotations with the drug culture, particularly in the USA in the context of the Drug Paraphernalia Laws(*). Indeed, peoples of the Middle East are always shocked when they hear or see that the shisha they have been using for centuries in convivial settings, is portrayed in the West as a mere drug taking device.
If only one among the 3 major universal words (Hookah, Narghile, Shisha) had to be kept, I would personally recommend Shisha. On one hand, this word is used everywhere in the world. It can be easily pronounced and memorised by almost any individual in the world (remember why the commercial word “Kodak” was chosen). On the other, like “Hookah” (Arabic for urn), “Narghile” (Sanskrit then Persian for coco nut) and “Goza” (Egyptian Arabic for coco nut), Shisha is consistent with the wide diversity covered by an anthropological genus that perfectly reflects the phylogenetic link between the common element (water recipient) and its remote –and considered so important- origin when a coco nut, half filled with water, was used as a smoke filter. From this perspective, Shisha is highly generic, understood as descriptive of all members of a genus.
I also think the question of sharing knowledge among researchers has no relation with the words by themselves, be they narghile, hookah, shisha or “water-pipe”, but rather with the will to cooperate and take stock of the existing work carried in this field (*) and in any language. Unfortunately, this has not been done when a report for a supranational organisation (WHO), supposed to be based on a “world review”, was recently prepared on this subject. Besides, I may wonder where the real linguistic standardisation problem lies when recurring studies (Natto 2005 and Tamim 2006, just to mention recent ones) mistake one product for the other. Finally, the selection of one word should have been discussed among researchers. Unfortunately, this did not happen so the related choices are obviously arbitrary and hence, questionable.
Kamal Chaouachi
(*) Cited references: inhttp://tc.bmjjournals.com/cgi/eletters/15/suppl_1/i24#544
Conflict of Interest:
None declared. - Published on: 13 May 2016Shisha, Goza, Hashish and Street Children: What the Egyptian Scene Teaches Us
- Kamal Chaouachi, Researcher in Socio-Anthropology and Tobaccology
Show MoreShisha, Goza, Hashish and Street Children: What the Egyptian Scene Teaches Us
For historical, sociocultural and health reasons, Egypt is cer...
Show LessShisha, Goza, Hashish and Street Children: What the Egyptian Scene Teaches Us
For historical, sociocultural and health reasons, Egypt is certainly the most important country in the world regarding shisha smoking (*). So, many thanks to Pr Fouad Al-Belasy and his colleagues for the very rich comments about the Egyptian Goza and Shisha. This showed, once more, the complexity of the issue and how different from the cigarette world it is. It is not everyday that we have a scientist with such hands-on experience and whose studies, particularly the last one in the Journal of Oral and Maxillofacial Surgery, definitely reflects such qualities.
MOLLASSES. In his contribution, the tobacco-mollasses mixture (mu‘assel; and “maassel” in Egyptian Arabic…) is said to be unflavoured. I would like to inform him that in other countries, particularly Arab countries, the same word is employed for the flavoured product as well. And when the unflavoured product is used, it is sometimes called jurâk.
BOURY. “Boury” can be used synonymously for Shisha, he says. I would like to note that in a country like Yemen, such a word represents the clay bowl of the madâ‘a (the national narghile) filled with tumbak (raw tobacco)(*). I assume that this is a metonymic description as it often happens in this field. For instance, “hookah” is literally an Arabic word (for “urn”, e.g. of water) and similarly “shisha”, which means, in Persian, something like a “bottle” (sise in Turkish). In Asia, the same linguistic transfer seems to occur where “chillum” may mean the bowl but sometimes, also, the hookah itself (*).
GOZA. What Pr Al-Belasy states about the Goza (take care with the different spellings – perhaps we should keep “Goza” and forget about “gooza” and “gûza”), and the description he gives of its material details (from the valve to the reed and from the lighter to the “bilya”…), and how they are used (body techniques), are indeed very important because of their deep consequences on the related biomedical studies. I would like to add that, my own work also contains similar descriptions of the Goza and its users. For instance, I quote a popular song by M. Sêlem (‘El-Kîf) where the whole atmosphere of a Goza party is depicted as in Pr Al-Belasy’s input (*). I have also carried on an analysis of a book by Egyptian Nobel Prize Naguib Mahfûz (Tharthara fawqä n-nîl) in which the Goza is used as a mere pretext (a relevant key sociological notion), being described in almost every page of the novel (*). To close this chapter, thank you for recalling Salem, a pioneer in research on Goza smoking, author of so many valuable studies on it (see our Tetralogy)(*).
HASHISH.As for the use of hashish in the goza, Pr Al-Belasy’s anthropological description (in the true sense of the word) of its smokers is also very interesting. In my chief work, I also provide extensive narrative depictions of situations where such odd characters as the Me‘ellem (Sultan), his wife the Me‘ellema, and other colourful actors of the “gurez” (secret smoking rooms) “sign” their goza by placing the substance inside the bowl (*).
CHILDREN SMOKING. What Pr Al-Belasy tells us about children and smoking in his country is very useful because there has been a lot of confusion in this respect. He is a personal witness of how poverty may transform the “commonly accepted traditions” that maintain children away from smoking. In the poor countries, not only shoe-shine boys at work are commonplace scenes but also children selling cigarettes in the streets. For them, the cafés are a natural and important place because there are many potential clients. They are also a place where they can rest a little. Now, if you were such a street child, probably in charge of several brothers and sisters, you would feel that you have quickly become an adult simply because you spend a great part of the day working in adult environments such as the above cafés.
Consequently, from time to time, you may try to reward yourself because the child is still in you. Why not ask for a delicious “apple, peach, banana, or cherry shisha” since nobody in society cares for you and your brothers and sisters anymore ? Neither the walkers nor the employees of the coffee-shops would try to exert any kind of moral or social control over you. You see, if these children were normal, i.e. if they were not poor, of course their parents would never let them ask for such a product and would let them clearly understand that this is forbidden. Alternatively, they could find out that it is a kind of “rite of passage” to the world of men and grown-ups. In these conditions, they would learn, instead, to ask for an ice-cream flavoured with the same above fruits...
Kamal Chaouachi
(*) Cited references (KC 1997, 2000, 2001): please go to http://tc.bmjjournals.com/cgi/eletters/15/suppl_1/i24#544
Conflict of Interest:
None declared. - Published on: 13 May 2016The issue of nomenclature
- Wasim Maziak, Researcher
Show MoreI thank the authors of letters regarding our published work (Ward et al, 2006) on their useful remarks. It is self-understandable that no one uses the world waterpipe when asking the public about this tobacco use method, but use the local word for it. The same way that we never ask the public about ischemic heart disease but use this term extensively in research papers about this problem. It is also understandable that t...
Show LessI thank the authors of letters regarding our published work (Ward et al, 2006) on their useful remarks. It is self-understandable that no one uses the world waterpipe when asking the public about this tobacco use method, but use the local word for it. The same way that we never ask the public about ischemic heart disease but use this term extensively in research papers about this problem. It is also understandable that there is a need to use some unified term related to this tobacco use method in order to facilitate the indexing, search, and communication of research results related to this tobacco use method. While the waterpipe may not be a perfect term, local words describing this method (hookah, shisha, narghile, etc) can not be used as a unified term because of their local nature. The term waterpipe has the strength of highlighting a unique and unifying feature of all these local types; that is the passage of smoke through the water before inhalation by the smokers. In the end, people are free to use whatever term they see optimal in their research papers, but having a unified term at least in their key words will increase the potential of sharing their research results with all interested in this issue.
Wasim Maziak, PhD
Syrian Center for Tobacco Studies
Conflict of Interest:
None declared. - Published on: 13 May 2016A Commentary on Two Conclusions
- FOUAD A. AL-BELASY, Professor of Oral Surgery and Vice Dean
Show MoreDear Editor,
This is to comment on the following recently published eletter:
Chaouachi K: Syria, Lebanon, Tobacco Research in General and Narghile (Hookah, Shisha) Smoking in Particular. TC Online 8 June 2006.
I completely agree with the statement that Shisha is now used internationally because of the global hookah craze whereas “waterpipe” is no hypostasis and adhere to the notice that this wo...
Show LessDear Editor,
This is to comment on the following recently published eletter:
Chaouachi K: Syria, Lebanon, Tobacco Research in General and Narghile (Hookah, Shisha) Smoking in Particular. TC Online 8 June 2006.
I completely agree with the statement that Shisha is now used internationally because of the global hookah craze whereas “waterpipe” is no hypostasis and adhere to the notice that this word creates bibliographic noise in databases since it also refers to household infrastructure plumbing equipments [1]. Goza and Boury, however, are two other common names in Egypt. While Shisha and Boury may be synonymously asked for in a café shop by tobacco smokers in Egypt, Goza- not available now in all café shops- is the favorite for some smokers; especially Hashish smokers.
The use of Shisha as a substitute for cigarettes after quitting, and the fact that Shisha triggers relapse for some cigarette quitters is indeed a unique and worrisome observation [1, 2]. In addition, the initiation of Shisha smoking by a significant number of cigarette smokers is truly a significant unintended consequence of cigarette smoking cessation. While tobacco smokers who are only Shisha smokers never initiate cigarette smoking upon quitting, cigarette quitters may initiate Shisha smoking. However, cigarette quitters who initiate Shisha smoking are highly expected to resume cigarette smoking because they soon realize, under the effect of nicotine dependency, the ease of smoking a cigarette while reading, driving or talking in the telephone, for example.
References: 1- Chaouachi K: Syria, Lebanon, Tobacco Research in General and Narghile (Hookah, Shisha) Smoking in Particular. TC Online eletter 8 June 2006. 2- Ward KD, Eissenberg T, Rastam S, Asfar T,Mzayek F, Fouad MF, Hammal F,Mock J, Maziak W: The tobacco epidemic in Syria. Tobacco Control 2006; 15; 24-29.
Conflict of Interest:
None declared. - Published on: 13 May 2016A Personal Experience with Goza and Shisha Smoking
- Fouad A. Al-Belasy, Professor of Oral Surgery and Vice Dean
- Other Contributors:
- Stephanie Fulton, Thomas L. Wilding, and Frances Groen
Show MoreBeing a son of a famous well-qualified owner of a café shop, I have been, since the early days of my perception, in direct contact with Goza and Shisha smokers. Goza is a modified form of Shisha. It has its head, body, water-container, and hose [1]. However, Goza has no mouth-piece separated from the hose and no disposable plastic mouth-piece is served or commonly used. Yet, the water-container of Goza was and still is ma...
Show LessBeing a son of a famous well-qualified owner of a café shop, I have been, since the early days of my perception, in direct contact with Goza and Shisha smokers. Goza is a modified form of Shisha. It has its head, body, water-container, and hose [1]. However, Goza has no mouth-piece separated from the hose and no disposable plastic mouth-piece is served or commonly used. Yet, the water-container of Goza was and still is made from metal and the hose is 1 -1.5 meter long semi-dry sloping reed in which the partitions are hollowed through the use of a thin heated auger (not anyone can do this). Moreover, the water container of Goza has a small opening covered by a small piece of soft leather fastened by rolling several loops of thread or elastic to the lower end of the body, which acts as a valve allowing smoke entrapped in the vacuum space to be expelled between inhalations or before use by a sharing smoker. However, this valve ("Raffas") was devoid in earlier Goza. Serving both Goza and Shisha necessitates changing water from time to time, frequent cleaning of the body internals using a thick heated auger followed by several washings using hot water, and flaming of the lighter before being placed over the head. Unlike Shisha, however, the water- container of Goza can be placed in a small basin filled with cold water while not in use. But, Goza necessitates holding it while smoking; usually by the smoker himself. In this respect, it is interesting to say that some Goza smokers were seen to fantastically design a metallic short stand with a movable ball bearing socket in order to avoid keeping hold of Goza and to freely pass the hose from one smoker to another. This altogether with decorations of Goza or Shisha implies the deep effect of the habit on some smokers. Up to the nineties of the passed century, only adults and elderly men were seen smoking Goza or Shisha. It was extremely rare to see a child (17-19 years old) who smokes Goza or Shisha. To my experience, having a seat and table in a café shop was only an act of adults. Children were not allowed to enter any café shop except for watching the T.V. No child could dare to ask for Goza or Shisha otherwise he will be forced out or remembered to his parents or guardian. Moreover, a cigarette smoking child was considered violating the commonly accepted traditions of society. However, cigarette smoking by homeless children was only accepted and pitied at the same time by society during these days. Therefore, with the dramatic changes in the accepted norms by new societies, it has become usual to see a café shop partly occupied by children smoking tobacco. From another perspective, maassel was and still is the most commonly used tobacco in Goza or Shisha smoking. Maassel is of three common degrees: hot, moderate and cold. Flavored tobacco, on the other hand, has become widely available in most café shops. Both can be provided in the café shop by the server but maassel; in addition, can be purchased by the smoker himself. Unlike maassel, flavored tobacco can be easily smoked by a child without feeling lightheadedness, headache or an altered state of consciousness. Therefore, it has become usual to see children in café shops asking for an apple, peach, banana, or cherry Shisha. They usually ask for it cheerfully as if they were asking for a drink. However, in underdeveloped or developing countries a question may be raised about home circumstances, financial support and character of the child who can pay for multiple drinks as well as Shisha smoking in a café shop. In the past, smoking Goza or Shisha by elderly females was accepted by society and considered as equal or parallel to snuff dipping or snuff inhalation; a habit that was widely prevalent among old females at that time. While the habit of smoking tobacco by adult females was considered pornographic, only adult female with the nickname "Mealemma" {(Master) or a female in charge of a café shop or agency for example} was accepted as a Shisha smoker. At the present time, with the wide prevalence of Satellites, and Media over-flow [2] as well as sexual effects, it has become familiar to see adult females sitting freely in café shops and smoking flavored Shishas. Maassel can be considered the most commonly used tobacco by dependent Goza or Shisha smokers. Some of those dependent Goza or Shisha smokers may be Hashish smokers. In the past, most café shops had an isolated corner for Hashish smokers who were given a due consideration by the server. However, because of a governmental pursue the habit of Hashish smoking has been almost eradicated in café shops. Nevertheless, "Bango" (an intoxicating plant leaves) has become the alternative despite the war against both. Serving a Hashish or Bango smoker differs from serving a maassel or flavored tobacco smoker. Maassel or flavored tobacco smoking is served by asking for alternative heads on an individual basis where the server is entirely responsible to provide a highly working Shisha or Goza with the head fully filled with tobacco and covered with a burning lighter. in Hashish smoking, however, a set of heads usually five or ten made from crockery are first filled with maassel and placed before the smoker over a wooden stand where the smoker covers maassel with Hashish cut into small discs (approximately .5-1mm thick and .3-.5 cm in diameter) or Bango spread over in a coarse powdered form. This entails that the head in Hashish smoking is only 1/4 filled with maassel ("Tasheirah"). Moreover, and unlike maassel or flavored tobacco smoking, the server in Hashish smoking will join the smoker where he is required to change the heads, flame the lighter before every time another head is used and even share in smoking. While cigarettes can be filled with Hashish or Bango to have a "Saroukh" (rocket) by some smokers, Goza or Shisha is essentially instrumental in Hashish or Bango smoking habit. This simply may be a corollary to the well known fact that Goza or Shisha smoking is a social habit practiced and shared in groups. In addition to health hazards relevant to the used tobacco, type of lighter as well as the risk of disease transmission through sharing the hose of Goza [3-5], Hashish or Bango smoking becomes more hazardous. Therefore, endeavors and strategies aimed at understanding, analyzing and preventing this habit should be developed and implemented by all concerned authorities.
References
1. Maziak W, Ward KD, Afifi Soweid RA, Eissenberg T: Tobacco smoking using a waterpipe: a re-emerging strain in a global epidemic. Tobacco Control 2004; 13: 327-333. 2. Chaouachi K: Eletters: About the so-called epidemic and the poor smoking people - Ward KD, Eissenberg T, Rastam S, Asfar T,Mzayek F, Fouad MF, Hammal F,Mock J, Maziak W: The tobacco epidemic in Syria. Tobacco Control 2006; 15; 24-29. 3. Salem ES, Sami A: Studies on pulmonary manifestations of goza smokers. Chest 1974; 65:599. 4. Shihadeh A: Investigation of mainstream smoke aerosol of the argileh water pipe. Food Chem Toxicol 2003; 41:143–52. 5. Al-Belasy FA: The relationship of "shisha" (water pipe) smoking to postextraction dry socket. J Oral Maxillofac Surg 2004; 62:10-14.
Conflict of Interest:
None declared. - Published on: 13 May 2016Syria, Lebanon, Tobacco Research in General and Narghile (Hookah, Shisha) Smoking in Particular
- Kamal Chaouachi, Researcher in Socio-Anthropology and Tobaccology
Show MoreDear Editor,
This is to comment on the following recently published study:...
Show LessDear Editor,
This is to comment on the following recently published study:
Ward KD, Eissenberg T, Rastam S, Asfar T,Mzayek F, Fouad MF, Hammal F,Mock J, Maziak W. The tobacco epidemic in Syria. Tobacco Control 2006;15;24-29.
About the So-Called Epidemic and the Poor Smoking People
The paper is globally unbalanced in favour of a certain focus on narghile (hookah, shisha) smoking. After reading the three following quotations, the reader may wonder whether we can call hookah smoking an “epidemic” in Syria:
1-"The prevalence of cigarette smoking was 56.9% for men and 17.0% for women, while the prevalence of waterpipe smoking was 20.2% for men and 4.8% for women (fig 1)"
2-"The opposite pattern was observed for waterpipe, with 1.0% smoking daily (1.4% for men and 0.6% for women), and 10.6% smoking occasionally (18.8% of men and 4.2% of women). The prevalence of combined daily use of cigarette and waterpipe was reported rarely—0.1% (0.1% men, 0.1% women)."
3-"Daily cigarette smokers averaged 20.8 (SD 14) cig/day (23.6 (13.9) for men and 12.8 (11) for women), while weekly waterpipe smokers smoked on average 1.7 (1.1) waterpipe/week (1.6 (1) for men and 1.7 (1.4) for women)."
We encourage our colleagues to inform the Syrian Ministry of Health of these statistics and urge it to take steps to curb the cigarette epidemic in this country. Of course the task is huge because of the nature of the market and the diverse interests at stake. Syrians smoke national, international, smuggled and counterfeited cigarettes. Certainly the solution is regional integration and cooperation. Syria and Lebanon, where more than a half of the population smokes cigarettes in both countries, can work hand in hand towards a Middle East free from tobacco all the more that they are one same people.
So, we are afraid “epidemic” might not be the best word to describe the revival of narghile use in the Middle East. Besides, a corresponding scenario was proposed two years ago by the same team (1). According to it, the Arab information satellite television channels would have been greatly responsible for the development of the hookah craze. Unfortunately, such a conclusion is not in agreement with our socio-anthropological research findings in the Middle East which point to at least 15 factors set out and analysed in an early document (2).
Now, if "quitting is also more prevalent among waterpipe smokers especially in the poorer sections of the society", then this is good news because one reason behind the failures of many tobacco prevention programmes in the world is not dealing with the health consequences of poverty in this field. By good fortune, great original researchers showed how marginalized groups adopt unexpected strategies to adapt to any new situation stemming from rises in tobacco prices. Just to mention some of them, they may leave shorter butts which is unfortunately an extremely hazardous behaviour (3). They may also hand-roll cigarettes that pose higher oral cancer risks (4). More, they can stuff hand rolled cigarettes with the remaining tobacco from the butts of other, used filters and dry leaves, or share the same cigarette (5).
About Carbon Monoxide Levels
“Results suggest that waterpipe users are exposed to more CO than previously reported (we observed a mean increase from 5.6 ppm before use to 36.3 ppm after use (p , 0.01), compared to the mean of 14.2 ppm after waterpipe use reported by Shafagoj and Mohammed)”.
This fact may be surprising for the authors. However, this is in agreement with our own findings so we will be happy to comment on it but only when the corresponding study is out since it is only an announcement. Indeed, we regret that the authors too often refer to forthcoming publications.
About the Adaptation of Questionnaires
Kozlowski actually warned against the misuse, in English, of the words “craving” and “urge” (6, 7). So, we really wonder how, in a sophisticated language like Arabic, these concepts, and the subtleties they convey, will be rendered in a corresponding translated questionnaire. Many studies in this field refer to “adapted” versions of internationally known and validated questionnaires (like Fagerstrom’s, Tiffany–Drobes’, Prokorov’s, Hughes-Hatsukami’s, etc.) and, sometimes, to an Arabic “version” of them. However, they are never made public. Since science is based on the possibility offered for any researcher to reproduce, in the same conditions, any experience previously carried on, we think the so-called documents should be annexed to the studies publishing the corresponding results. Indeed, it is all the more easy that in most cases the adapted questionnaires are very short in length. From there, we hope to see the Arabic version of the Tiffany-Drobes questionnaire published soon so our team, presently working on dependence patterns, can test, in its turn, its claimed applicability.
Also note that the same Kozlowski warned against the use of smoking machines in the field of cigarettes, where, however, the smoking session (c. 5 minutes) is extremely short in comparison with the hookah (30-60 minutes)(8). So, this kind of cogent reflection may render questionable a certain number of findings (9).
About Initiation Age
Strangely enough, statistics reveal that there is no so-called children use in Syria:
"Age of initiation differed according to method of smoking and gender. On average, men initiated use of cigarettes at age 17.9 (5.3) years and waterpipe at 25.5 (9.1) years, while women initiated use of cigarettes at 22.5 (8.4) years and waterpipe at 28.9 (9.9) years (p , 0.05 for all gender and smoking method comparisons by t test)."
Consequently, and since Syria is an Arab country, this result is apparently not in agreement with the first Advisory Note on “Waterpipe” smoking ever published by WHO (World Health Organisation). This last document states, among other errors that could have been avoided, that in the Arab world (described as “South-West Asia and North Africa”): “it is not uncommon for children to smoke with their parents” (10). In fact, our socio-anthropological work showed that in Syria as in many other countries of the region, narghile (hookah, shisha) initiation is more akin to a kind of “rite of passage” (2).
About Dependence
"Less interest in quitting and a higher quit rate among waterpipe users compared to cigarettes possibly indicate lower level of nicotine dependence among waterpipe users."
In a former study (11), on which we already commented (12), one assumption was that"nicotine dependence may also result from repeated inhalation of tobacco smoke from a waterpipe [...] Until recently, no studies have characterised a waterpipe withdrawal study of seven waterpipe using men, daily use was associated syndrome, though some of the hallmarks of dependence are apparent: continued use despite potential health risks, financial cost, and reported inability/difficulty quitting."
In order to spare time and from our original transdisciplinary experience, we would be happy if our colleagues would accept to contemplate other possible research orientations in this important field. Indeed, on one hand, original research on narghile will help, not only understand the dependence phenomenon related to the use of narghile, but also the dependence process as a whole and, most importantly, regarding cigarette smoking. People do not necessarily smoke the hookah for nicotine and another evidence for this is that the fashionable “hookah lounges” already offer herbal fruit-flavoured tobacco-free smoking mixtures to their patrons.
On the other hand, there is a serious debate over the central role of nicotine in the dependence process (13). Indeed, the importance of flavours (only in the case of tobamel, the popular tobacco-molasses based smoking mixture) would make the dependence very similar to that induced by coffee (14). Thus, not only nicotine but MonoAmine Oxidase Inhibitors (MAOI), other not so « important » low-dose potentially dependence-inducing alkaloids, ligands of opioid receptors, and other substances, might play a not so minor role in the dependence process (15).
About Anthropological Work
The paper refers to a “new” orientation of the team activities within the framework of the so-called “grounded theory approach”. Here, we would like to emphasise that the anthropological work implies very long observation periods. In our case, we actually carried on early socio-anthropological work in the Middle East for a period of four years. We have interviewed hookah users and drawn, only in the last stage, relevant and original conclusions, particularly regarding dependence (2). We regret that the authors openly present “preliminary” results or analysis of an ongoing work of this nature. This is not possible. From the very methodological point of view of anthropology, we are afraid this cannot be done and this is one of the peculiarities of some social sciences.
Poland et al. have clearly shown in the columns of this journal where the last frontiers of tobacco control are (16). Their rare and deep analysis is valid for any country. In the light of the debate over orientalism opened by Edward Saïd (17) to an unexpected horizon, we scientists (particularly from the Middle East or of Middle East origin), either from the biomedical or social science field, will be answerable for the way we have been doing science (18). Do we make it with the people and for the people and their health or for academic research only - sort of Art for art’ sake ? From this perspective, we commented on Poland’ study and showed the actual similarities and dissimilarities between both the cigarette and hookah worlds (19). So, why not take advantage of the recent archives of this journal ?
A statement we fully agree is : "What is unique and worrisome about the waterpipe is its use as a substitute for cigarettes after quitting, and the fact that the waterpipe was the trigger of relapse for some cigarette quitters. Thus, initiation of waterpipe use can be a significant unintended consequence of cigarette smoking cessation." Indeed, we are glad to see how our colleagues now share the conclusions we drew more than five years ago (2, 20, 21).
About the word “water-pipe”
We are afraid this word is misleading and deepens the gap between scientists and the true world of hookah users. Please refer to our critique of a paper in the columns of this same journal (22). Indeed, we are quite sure that our colleagues will never use, in a related study or questionnaire into Arabic, “galyûn bi-l-mâ‘ (or galyûn mâ‘î), which are, as they may know, laughable literal translations of “water-pipe”. We are sure they would use the words “narghile” or “shisha” (“hookah” if they were in India or Pakistan). Indeed, they will understand that it would be funny to imagine a naïve anthropologist asking smokers in a Syrian coffee-house: What about your “galyûn bi-l-mâ‘” practice ?
Indeed, in this field where tradition and the sociocultural context meet so closely with pharmacology, it is of utmost importance to use the language the people use then reflect this in our publications. Further to a comprehensive analysis of the world linguistic variations and the higher observed prevalence for some of them, we concluded that three terms are highly relevant: narghile , hookah and shisha (2). These words can be found in any good English academic dictionary. Shisha is now used internationally because of the global hookah craze whereas “waterpipe”, we are afraid, is no hypostasis. More, we have noted how this word creates bibliographic noise in databases since it also refers to household infrastructure plumbing equipments… Certainly the artefact is a “water-pipe” in a chemistry laboratory (9). However, once you are in the street or in a domestic setting, it is a hookah, a narghile, a shisha and even much more. This stresses, once more, the importance of a scientific discipline like anthropology whose object is not the study of folklore.
About Capacity Building
The so-called RAM (Research Assistance Matching) action was already advertised in the Science journal and we had the opportunity to comment on it by emphasising the fact that the best studies in the field of hookah smoking have been carried on in the South with no external aid (23). For instance, who could say that Shafagog (24), who worked with a small team in a poor country like Jordan, was lacking know-how, ignoring international best practices or expertise ? He has actually produced the best reference studies on cotinine/nicotine levels and an excellent other one on CO intake in true narghile smokers.
The same applies for Sajid (25) and his team in Pakistan, whose findings, obtained with modest means, contributed in pushing forward research. He had this fantastic idea of measuring CO levels according to the size of the device, the nature of the tobacco-based mixture and even the charcoal varieties. He and his colleagues are simply brilliants. They remained relatively unknown for a very long time until we described their work six years ago then advertised it here and there (2). We could follow with many other examples from the so-called South.
So, what we defend is a capacity building project that takes into account other dimensions than the RAM one. The objective of ours, hopefully soon carried on with the collaboration of the prestigious University of La Sapienza, is to train Western researchers on the specificities of the socio-cultural context of the countries where hookah smoking seems to cause a problem for certain authorities. Perhaps the RAM project may be of some use for cigarette smoking. However, for narghile, our own opinion is that we definitely need not new or modern methodologies or approaches. What we need are ideas that originate from the local context. We have already helped dozens of researchers in this new way of thinking and we hope to train more and more people in the future on these trailblazing conceptual frameworks.
Kamal Chaouachi,
Researcher in Socio-Anthropology and Tobaccology
Consultant in Tobacco Control (Paris)
REFERENCES
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(2) CHAOUACHI Kamal. Le narguilé : analyse socio-anthropologique. Culture, convivialité, histoire et tabacologie d’un mode d’usage populaire du tabac. Transdisciplinary doctoral thesis, Université Paris X (France), 420 pages. [Engl.: "Narghile (hookah): a Socio-Anthropological Analysis. Culture, Conviviality, History and Tobaccology of a Popular Tobacco Use Mode”].
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(8) ZIELINSKI S. Smoking Machine Test Inadequate and Confusing, But No Replacement a Decade Later. Journal of the National Cancer Institute 2005 (Jan 5); 97 (1): 10-1.
(9) SHIHADEH A, SALEH R. Food and Chemical Toxicology : Polycyclic aromatic hydrocarbons, carbon monoxide, “tar”, and nicotine in the mainstream smoke aerosol of the narghile water pipe. Food and Chemical Toxicology 2005; 43(5): 655-661.
(10) WORLD HEALTH ORGANISATION. Advisory Note: Waterpipe Tobacco Smoking: Health Effects, Research Needs and Recommended Actions by Regulators. Tobacco Free Initiative 2005. Retrieved 15 Dec. 2005 from: www.who.int/tobacco/global_interaction/tobreg/en/
(11) MAZIAK W, WARD KD, AFIFI SOWEID RA, EISSENBERG T. Tobacco smoking using a waterpipe: a re-emerging strain in a global epidemic. Tobacco Control 2004; 13: 327-333.
(12) CHAOUACHI K. eLetter to the Editor: Serious Errors in this Study. Tobacco Control 2004 (2 Dec.). A critical analysis of the above study http://tc.bmjjournals.com/cgi/eletters/13/4/327
(13) FRENK HANAN, DAR REUVEN (book). A Critique of Nicotine Addiction. Kluwer Academic Publishers (Boston) 2000.
(14) CHAOUACHI K. Tabacologie du narguilé [Eng.: Tobaccology of Narghile]. Alcoologie. 1999; 21 (1/83):88-9.
(15) MOLIMARD R.. Dépendance, la nicotine est-elle la seule responsable ?[Eng.: Dependence. Is nicotine solely responsible ?]Soins Psychiatr 2001 (May-Jun);(214):33-5.
(16) POLAND B, FROHLICH K, HAINES RJ, MYKHALOVSKIY E, ROCK M. SPARKS R. The social context of smoking: the next frontier in tobacco control?. Tobacco Control 2006;15:59-63.
(17) SAID Edward (book). Orientalism. Routledge & Kegan Paul 1978 (London).
(18) CHAOUACHI K. Culture matérielle et orientalisme. L’exemple d’une recherche socio-anthropologique sur le narguilé. Arabica, tome LIII,2, 177-209. Koninklijke Brill NV (Leiden) 2006. [Engl.: Material Culture and Orientalism. The Example of a Socio-Anthropological Research on Narghile](www.brill.nl )(available here or contact author)
(19) CHAOUACHI K. Letter to the Editor: The Social Context of Individual and Collective Smoking: Similarities and Differences. Tobacco Control 2006 (1 April). A critical analysis of Poland’ study. http://tc.bmjjournals.com/cgi/eletters/15/1/59
(20) CHAOUACHI K. Shisha, hookah. Le narguilé au XXIe siècle. Bref état des connaissances scientifiques. [Eng.: Narghile, Hookah in the 21st Century: An Overview of the Scientific Knowledge]. Le Courrier des Addictions 2004 (Oct) ; 6 (4) : 150-2. Full English version available.
(21) CHAOUACHI Kamal. A 60 page tetralogy on narghile (hookah) smoking and health published in Tabaccologia, the official Journal of the Italian Society of Tobaccology: Introduction (Tabaccologia 2005; 1: 39-47); Pharmacology (2005; 3: 27-33); Health Aspects (2006;1:27-34); Prevention (forthcoming). Includes English abstracts. www.tabaccologia.org/archivio.htm
(22) CHAOUACHI K. Letter to the Editor: Some Misconceptions in a Good Alert Paper. Tobacco Control 2006 (18 Jan.). A critical analysis of the following study: AFIFI-SOWEID Rima. Lebanon: water pipe line to youth. Tobacco Control 2005;14:363-4.
tc.bmjjournals.com/cgi/eletters/14/6/363-a#479
(23) CHAOUACHI K. Letter to the Editor: Arabs Neither Need a Scientific Revolution Nor Are They a Cultural Exception. Science (eLetter, 07 March 2006). A critical analysis of the following study: MAZIAK W. Global voices of science. Science in the Arab world: vision of glories beyond. Science. 2005 Jun 3;308(5727):1416-8.
http://www.sciencemag.org/cgi/eletters/308/5727/1416#3253
(24) SHAFAGOJ YA, MOHAMMED FI, HADIDI KA. Hubble-Bubble (Water Pipe) Smoking: Levels of Nicotine and Cotinine in Plasma, Saliva and Urine. Int J Clin Pharmacol Ther 2002; 40(6):249-55.
(25) SAJID KM, AKTHER M, MALIK GQ (1993 Sep). Carbon monoxide fractions in cigarette and hookah. J Pak Med Assoc.; 43(9):179-82.
Conflict of Interest:
None declared.