Dilshad Jaffa, Anant Kumarb
a. Gillings School of Global Public Health at the University of North Carolina, Chapel Hill, USA.
b. Xavier Institute of Social Service, Ranchi, Jharkhand, India.
Tobacco use and smoking is among the top five causes of mortality and morbidity in Kurdistan region of Iraq. The Kurdish Association for Fighting Smoking reports that 54 percent of the Kurdish population smokes. Although smoking is not new in Kurdistan, hookah smoking has emerged as a new fashion among both young men and young women. The commentary is an attempt to understand and highlight this emerging concern and public health epidemic which needs immediate attention from the public health officials. A review of the global hookah smoking trend suggests that hookah use may ‘represent the second global tobacco epidemic since the cigarette’.
Tobacco use and smoking is among the top five causes of mortality and morbidity in Kurdistan region of Iraq.1 The Kurdish Association for Fighting Smoking reports that 54 percent of the Kurdish population smokes. The study also reports that smoking cigarettes has increased in recent years, particularly among youths and poor people.2 Although smoking is not new in Kurdistan, hookah smoking has emerged as a new fashion both young men and young women.
Hookah, also known as a water pipe (shisha, narghile in Kurdistan) is a long, flexible tube that draws the smoke through water contained in a bowl (Figure 1). It has various sizes and shapes. A modern hookah has a head (with holes in the bottom), a metal body, a water bowl, and a flexible hose with a mouthpiece which is used to smoke specially made flavoured tobacco. Although many users think it is less harmful, hookah smoking has many of the same health risks as cigarette smoking.3
Hookah smoking is prevalent in the middle-east, particularly in Iran, Turkey, and Egypt, but it was not in wide practice in Kurdistan.1 However, now it is increasingly available in cafés, restaurants and also in Kurdish homes.4 Perhaps in part due to increased availability, it is becoming more popular among youths, including young women. This development is interesting as cigarette smoking was not a socially and culturally accepted behaviour for women, but it seems that hookah is gaining acceptance slowly. Attracting men is the one reason Kurdish women report for smoking hookah.5
A review of the global hookah smoking trend suggests that hookah use may ‘represent the second global tobacco epidemic since the cigarette’.6 Prevalence data on hookah use in Kurdistan region of Iraq is limited, but there are indications of the growing popularity of this harmful habit. It is an emerging concern and public health epidemic which needs immediate attention from the public health officials. The Center for Disease Control’s (CDC, 2005) reports that the 8.7 percent hookah smoking rate, particularly among young girls in Kurdistan is a real concern7 which is on rise.4 The majority of the Kurdish population is not aware of its ill-effects and believes that hookah smoking is not harmful and are ignorant about its negative health consequences and outcomes such as lung cancer, respiratory disease and low birth weight in babies;8 and the negative health outcomes of the use of shared mouthpieces which may result in the spread of infectious diseases such as tuberculosis, herpes, influenza and hepatitis.3
Factors contributing into the epidemic
There are several factors which are directly and indirectly associated with the rise in number of hookah smokers in Kurdistan region of Iraq. Some of the reasons for this increase can be attributed to:
- Image and social acceptability
- Smoking is associated with independence, sex, success, adventure
- To get social approval from peer/friends
- Family influences
- Availability and access
Besides this, lack of knowledge and misconceptions of its harmful effect are widespread. According to local health experts many people, especially young people, are not aware of the harmful health effects of smoking hookah and they think that it is less harmful than cigarette smoking.4 Tobacco used in a hookah is often flavoured as it is soaked in honey or molasses, fruit or other flavours. This variety of flavours and its availability at a very cheap price in local shops, markets and supermarkets in almost every corner and street in that region is another factor. In addition to that, the number of unregulated new teahouses and cafés offering hookah is on the rise in Kurdistan. Unemployment,9 economic distress and the current ongoing armed conflict in the region are some of the direct and indirect cause of an increase in tobacco use especially among the youth population.
Discussion and Recommendations
The present political and economical crisis and the ongoing conflict have made it difficult for the government to focus and implement health and other developmental interventions. Despite the local Kurdish authorities’ initiatives and efforts, tobacco control policies and programs are proven insufficient in checking hookah use. This issue cannot be ignored considering the long term consequences on the health of the population, particularly the youth population and the society at large. Although the government has a policy and committed on tobacco control program, it needs proper enforcement.
Present tobacco control efforts in the Kurdistan Region of Iraq face a number of challenges such as unavailability of data regarding hookah use, which requires systematic research to understand more about the hookah user’s motivation and knowledge. The studies in the past have shown an increase in susceptibility index [to measure likely initiation of smoking among never smokers] among hookah smokers which includes never smokers.7 This is very alarming because the majority will continue to do so throughout adulthood and this rate is likely to rise further. Policymaking discussions and forums for tobacco control in Kurdistan should consider this issue on priority and focus on hookah smoking especially among youth.
The authors advocate that the government should identify hookah smoking as a serious emerging public health epidemic and suggest that the government should undertake and commission research studies to understand this epidemic. Currently, there are no specific data available on hookah smoking, associated disease incidence, prevalence, morbidity and mortality. Without which it would be difficult to understand the social, cultural determinants and other epidemiological factors responsible for the increase in hookah smoking particularly among youth. Thus, the authors suggest that the following steps as an immediate multidisciplinary collaborative intervention strategy.
- Studies and systematic research to understand more about the motivation and knowledge among the population, such as ‘formative research’,
- Develop an effective and sustained surveillance system to monitor hookah smoking behaviour,
- Start public health campaigns in schools and other educational institutionsfor prevention, and to increase awareness about its consequences and health outcomes especially among young women,
- Conduct region wide public awareness and education campaigns on the threats and health outcomes targeted toward young men and women in the community on this type of tobacco use
- Ensure an informed community health workers on the emerging and health outcomes of this public health threat,
- Regulate the entry of hookah tobacco and associated accessories into the region and hookah smoking at public places like restaurants, and cafés.
Tobacco control efforts in Kurdistan should be made more effective. It is an important first step to identify hookah smoking as an emerging public health epidemic, conduct systematic research and design policy and program initiatives for the control of hookah smoking particularly among youth. The government should develop a Comprehensive Hookah Control Program within the Tobacco Control Program based on scientific evidence and best practices.
Conflict of Interest: None declared
Acknowledgement: Authors are thankful to Jo Birckmayer for her comments and suggestions on the paper.
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- Kurdish News Network (KNN). Smokers on the Rise in the Kurdistan Region. 2014. [Source] http://www.knnc.net/en/full-story-31515-28-False#.VwvV53pWUsR. Accessed on 15 April 2016.
- Centers for Disease Control and Prevention (CDC). Smoking & Tobacco Use. Fact sheet on hookah smoking. Accessed February, 2016.
- The Kurdish Globe. Shisha smoking rising among Kurdish youngsters. 2013. Accessed on 15 April 2016.
- The Kurdish Globe. Female hookah smokers harassed. 2011. Accessed on 15 April 2016.
- Maziak W, Taleb Z, Bahelah R, Islam F, Jaber R, Auf R et al. The global epidemiology of waterpipe smoking. Tobacco Control. 2014;24(Suppl 1):i3-i12.
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- Centers for Disease Control and Prevention (CDC).Tobacco Use Among Students Aged 13–15 Years — Kurdistan Region, Iraq, 2005. Accessed on 15 April 2016.
- Akl EA, Gaddam S, Gunukula SK, Honeine R, Jaoude PA, Irani J. The effects of waterpipe tobacco smoking on health outcomes: a systematic review. Int J Epidemiol. 2010 Jun;39(3):834–57.
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- Unemployment on the rise in Iraqi Kurdistan: syndicate. 2015. Accessed on 15 April 2016.