Shisha guidance for GPs: eliciting the hidden history.

Waterpipe tobacco smoking (or 'shisha') is a 600-year old practice, commonly known as hookah, nargile, and hubble-bubble. It is a growing health concern of global significance, and published literature already points to an association with lung cancer, chronic lung disease, reduced birth weight, and oral disease. 1 Although traditionally perceived as being prevalent only in the Middle East and the Indian subcontinent, shisha is now endemic to much of the globe, including the metropolitan cities of the UK, where an estimated 8% of Birmingham university students are regular shisha smokers. In a study by Jackson and Aveyard (n = 937 students), 7.1% (48/637) of white responders were regular smokers, as were 10. of Arab, and 20% (1/5) of other ethnic origin respondents, indicating that regular shisha smoking among young UK adults may be, at present day, a cross-cultural fad. 2 DELIVERING A UNIFIED HEALTH MESSAGE As its popularity continues to grow, especially among young adults, there is an urgent need for shisha to be better understood and acknowledged among healthcare professionals, especially within primary care consultations so that it can be incorporated into existing evidence-based tobacco control strategies. It is undermining to public health efforts if healthcare professionals remain silent on shisha and do not acknowledge it as injurious to health. Such an approach may well be perceived by shisha smokers as tacit approval, if not promotion, of shisha being a safe alternative to cigarettes. 3 Shisha operates in an altogether unregulated industry, commonplace in cafes and restaurants. As yet, there is no legislation on the tobacco used in shisha beyond its prohibition indoors. 4 Unlike cigarettes, which have tight controls on the quantity of tobacco that can be used, shisha tobacco companies have largely been unopposed in producing ambiguous content descriptors, such as '0.5% or 0.05% nicotine, 0% tar' and 'natural flavours'. 5 Many shisha tobacco companies do not even display the tobacco content contained within and this gives credence to those who consider it a safe alternative to cigarettes. 5 Chemical analysis may be in its infancy, but emerging studies have already shown that there is sufficient toxicant exposure for healthcare professionals to take notice. 6 However, unlike cigarettes, harm should not be focused merely on the chemicals used, as many dangers of shisha are inherent to the design. In an ordinary session of shisha smoking, the tobacco is not usually fully consumed. 6 This has given rise …