Madam, It is a saddening fact that 1 out of every 5 Pakistanis has consumed more than 100 cigarettes/beedis or chillum/hookah ( all different forms of tobacco abuse) in his lifetime. 1 Encouragingly, there is a realization of the threat at the Government level and Tobacco control is one of the strongest components of National Action Plan for Prevention and Control of Non-Communicable Diseases (NAP-NCD). Country-wide Awareness programmes about the hazards of smoking, ban on cigarette advertisements on the local television network and dissuasion of tobacco cultivation are important steps in this regard. 2 What has been missing from these programmes is a focus on Non-Cigarette Tobacco abuse - a practice which has plagued our rural population for centuries in the form of Hookah and Chillum (water-pipe). Some of the potential hazards of water-pipe smoking were identified by Sajid KM et al in 1993. 3 More studies which indicate multiple adverse effects of water-pipe smoking have surfaced to literature in the recent years. However; the practice of water-pipe smoking not only remains prevalent in our villages, it is now also making its impact on the higher socio-economic urban strata in the form of Shisha.

A significant fraction of the tobacco abusers in our rural settings (40% of the males and 60% of the females) practice chillum and hookah and as a general perception these methods of tobacco abuse are thought to be less hazardous than cigarette smoking. 1 Although there is a dearth of prevalence studies regarding the practice of Shisha but it is becoming popularized in the urban settings as evidenced by the growing number of Shisha cafes in metropolis of Karachi and Lahore. The extravagant environment of these cafes and addition of enriching flavours to water-pipe are enough to attract large crowds throughout the year. A common myth about water-pipes is that the passage of smoke though the steaming water in water-pipes 'purifies' the smoke of all harmful elements. It has now been established through both the local and foreign studies that the commonly believed 'filtration' mechanisms of water-pipe are but a sham and serum CO and Nicotine after water-pipe smoking rise to levels almost comparable to those measured after cigarette abuse. 3,4 It has also been proven that long-term habitual abuse of water-pipe; just like regular cigarette smoking; is associated with lung, GI and bladder malignancies besides Pulmonary, Cardiovascular and Haematological impairments. Additional dangers not encountered with cigarette smoking may include infections such as Tuberculosis, Hepatitis C, Pulmonary Aspergillosis and H. pylori infection which have been hypothesized to spread from pipe sharing. 4,5
We recommend a multi-dimensional approach to combat the mounting problem. A documentation of rural and urban water-pipe providers should be initiated. An exploration into general community's knowledge and attitude towards water-pipe smoking is the need of the hour. The Government should start scrutinizing the existing Shisha cafes and ensure that only adults should have an access to water-pipe smoking. The existing country-wide anti-smoking campaigns should be expanded to include hookah and shisha into their focus. A discouragement of the practice at this stage would make certain that the evil is eliminated before it actually sets its roots into our social norms as it has in the Arab world.

Ali Jawaid, Omar Aftab
Medical College, Aga Khan University, Karachi.

1. Alam SE. Prevalence and pattern of smoking in Pakistan. J Pak Med Assoc 1998;48:64-6.

2. Nishtar S, Mirza Z, Mohamud KB, Latif E, Ahmed, Jafarey NA, et al. Tobacco control: National Action Plan for NCD Prevention, Control and Health Promotion in Pakistan. J Pak Med Assoc 2004;54:S31-S41.

3. Sajid KM, Akhter M, Malik GQ. Carbon monoxide fractions in cigarette and hookah (Hubble bubble) smoke. J Pak Med Assoc 1993;43:179-82.

4. Knishkowy B, Amitai Y. Water-pipe (narghile) smoking: an emerging health risk behavior. Pediatrics 2005;116:113-9.

5. Maziak W, Ward KD, Afifi Soweid RA, Eissenberg T. Tobacco smoking using a waterpipe: a re-emerging strain in a global epidemic. Tob Control 2004; 13:327-3.