Lessons from the recent case of CO poisoning due to shisha (hookah, narghile) tobacco smoking in Singapore

Dear Editors, In their interesting report, Lim et al. state that shisha CO poisoning is rare in Singapore [1]. The situation is actually the same worldwide. In Saudi Arabia, only 1 shisha smoker out of 24 cases of CO-related intoxications of various origins could be identified [2]. A few years ago, two cases related to hookah lounges were reported in France, a country with a total of about 1,000 neo-Orientalist smoking tea houses by that time [3]. Prevention should focus on the long overdue message that shisha smoking should never take place in poorly ventilated places, particularly when cigarette smoke is simultaneously generated [4]. A recent study from Jordan tends to support this key public health position [5]. Unfortunately, this message was not understood. On the one hand, traditional cafes in the Middle East, Asia and Africa are usually efficiently ventilated, contrary to their counterparts in other parts of the world. On the other hand, one basic difference between the traditional 4-century-old social use of hookah and the contemporary one is the nature of the heating source, which has changed over the last 2 decades from natural charcoal to commercial quick-lighting products [4]. It is unfortunate that Lim et al. did not provide a better description of the conditions in which the poisoning occurred. For instance, where did it take place: at home, in a coffee or tea house, or in the street? Was the place poorly ventilated? Was there simultaneous smoking of cigarettes or other tobacco products (cigars, pipes, etc.)? What about the charcoal and the size of the shisha? Was the smoking mixture tobamel/moassel (based on molasses and flavors added to the tobacco with no direct contact with the heating source) or jurak (a similar though stronger unflavored product in direct contact with the charcoal)? All these details are of great importance when evaluating the overall contribution to CO. A pioneering study has previously shown that the bigger the hookah is, the lower the amount of CO produced, and the latter also depends on the smoking product itself and the type of charcoal used (commercial vs. natural) [6, 7]. It is likely that in the case report the charcoal was of the quick-lighting type and the smoking mixture tobamel/moassel. However, it is also possible that it was jurak (a very popular product in the Arab-Persian Gulf region) [4] since the patient was said to be of Saudi descent …