Shisha Smoking and its Hazards

Abstract

This research was conducted to familiarize with the Hazards of Shisha Smoking among the youth of today, since past five years in the metropolitan city of Lahore. Primary and secondary sources were of great use. The information collected revealed that the teenagers are adopting Shisha as a style statement without knowing its health consequences. Cafes serving Shisha are considered to be rapidly increasing and therefore gain a big clientele. Besides being a growing trend it is a source of income to many suppliers. The study also found that smoking Shisha for an hour is as harmful as smoking 100 cigarettes. The need of the hour is to educate the youth regarding the harmful effects of smoking Shisha. Although a complete ban on anything is not possible, government should take steps to grip this growing culture.

Acknowledgements

We are grateful to ‘Almighty Allah' Who enabled us to complete this research paper. We are grateful to our instructor and our research supervisor, Ms. Rumessa Naqvi, whose proper guidance and apprehensive nature helped us to complete this research. We are thankful to Dr. Hassan Tariq (Medical Officer, Adil Hospital, Lahore), Ms. Madiha Jamil (Final Year Medical Student) for arranging the interview with the doctor and providing us with appropriate knowledge regarding some basic medical terms related to Shisha. We are also obliged to Mr. Muhammad Arslan (Worker at Mini Golf) for his time and effort in providing us with quality information during their interviews with the team. We are also thankful to Mr. Omer Javed Butt (owner of Cafe rock) and Mr. Usman Mukhtar Gondal (a regular consumer) for their valuable answers to our questions. Last but not the least we are obliged to our parents, siblings and fellow classmates for their love and support. We have divided our main research topic into 5 different domains.

Names	Domains
Usman Mukhtar Gondal	Social Significance
Zakra Chachar	Shisha Cafes
Resham Sohail	Clientele
Ameer Ismail	Health issues (Lung Cancer and Oral Cavity)
Saad Ali Khan	Health Issues (Nicotine Dependence, Passive Smoking, COPD and other related diseases)

Shisha Smoking and its Hazards Shisha originated in north westerns province of India, in the state of Rajastan and Gujrat. According to Cyril Elgood who does not mention his source, he was in India where Hakim Abdul Fateh Gillani an Iranian physician at the court of the Mughal emperor Akbar introduced the idea of Shisha..A  Following popularity among noblemen, this new device for smoking soon became a status symbol for the Indian aristocracy and gentry. Although Hooka has been prevalent in rural areas of Pakistan, it only recently entered in the urban areas in a substitute form of hookah which is known as Shisha. Shisha became very popular amongst youth when it was first introduces, gradually it founds it way to people's houses, parties, functions and events. Cafes and restaurants have gathered a lot of acknowledgement by adding Shisha in variety of flavours in their menu card. By seeing this acknowledgement almost all cafes are serving Shisha in Lahore. There are many problem been faced due to Shisha as it is a demerit good. Although some studies says that Shisha smoking is safer than tobacco cigarette smoking but medical professionals says that all kinds on smoking is bad for health, therefore Shisha stands at same level as is the cigarette regarding health issues. Each Shisha session typically lasts for more than 40 minutes, and consists of 40 to 150 drags that each consists of 0.15 to 0.50 litres of smoke. Hour long Shisha smoking is equivalent to 100-200 cigarettes; in a 45-minute smoking session a typical smoker would inhale 1.7 times the nicotine of a single cigarette. The water in Shisha use to filter diseases is not that efficient to remove all kinds of diseases. . People are suffering certain diseases as they had been a regular consumer of Shisha. Therefore Health issue is the main issue of Shisha consumption. A research department on Shisha smoking and cancer in Pakistan was published in 2008. Our scope of this research on Shisha is for last five years within geographical boundaries of Lahore. Our primary question for research is the hazards of Shisha. This we answered by acquiring knowledge of Shisha's four domains significance of Shisha, health issues regarding the usage of Shisha, cafes serving Shisha and problems faced by Shisha victims due to its ban.

Literature Review

The objective of this paper is to study and highlight the social, behavioral, and health related aspects as well as its externalities with regard to water-pipe smoking among adolescents in Lahore since last 5 years and also to create awareness among the youth. Water pipe, also known as Shisha, “Hubble Bubble”, “Narghile”, “Ghoza” and “Hookah”, has been in practice for the last 400 years. The reasons accredited to this trend are various misconceptions, that water pipe smoking is not hazardous to health. Another factor adding to its popularity is its social acceptability as compared to cigarettes and its portrayal is a symbol of modernization of our cultural heritage. (Anjum et al, 2007) The extent to which water pipe smoking has penetrated our society is difficult to establish since very little work has been done on it. A recent survey conducted in high socio-economic schools of Karachi reported that Shisha is gaining popularity among the young generation and it is easily available in the restaurants, hotels and Shisha cafes. This survey estimated that almost 70% children have experienced this form of tobacco, as young as seven years old. Its smoke also contains hundreds of potentially dangerous substances including carbon monoxide, charcoal, nicotine, arsenic, cobalt, chromium and lead causing disorders including lung and bladder cancers, impaired pulmonary functions, coronary heart disease, infertility, tobacco dependence and so on. (Anjum et al, 2008) Some research carried out in the UK last year showed that the people who regularly smoke `Shisha` may suffer from disastrous levels of carbon monoxide (CO) resembling to that of inhaling a car exhaust. In addition, water pipe smokers might absorb higher concentrations of these toxic substances because of higher concentrations in the smoke itself, or because they may smoke for several hours at a time and may inhale the moisturised, less irritating smoke more deeply. An hour-long `Shisha` session involves inhaling 100 to 200 times the amount of volume of smoke inhaled when smoking a cigarette. This menace of Shisha Smoking is fast spreading among school and college going students. According to a research, more than 1000 Pakistani children of ages between of 6-16 years take up smoking every day. Although the Anti-Smoking Ordinance 2002, clearly prohibits storage, sale and distribution of tobacco products near educational institutions, yet some leading universities, schools and colleges in Lahore allow Shisha Smoking on social events. Besides this a number of posters posted on walls and bookshops carry attractive offers for Shisha smokers. This is primarily meant to motivate the youth studying in nearby institutions towards Shisha smoking. In fact, every day new Shisha cafes are opening up in the country because of its increasing demand by the younger generation which is further pushing the youth towards the use of this menace. Smoking is also prohibited at all public places, including hotels and restaurants. Yet, it is being served in different cafes and restaurants of the vicinity. It is indeed sad that by allowing cigarette and `Shisha` smoking in these closed premises, the anti-smoking laws of the country are being disobeyed by almost all hotels and restaurants in the country. (Dr Javed Khan, 2010) The reasons for this rising trend are certain misconceptions that water pipe smoking is not hazardous to health, since the tobacco is filtered through water before inhalation; nicotine content is less than that of cigarettes and addition of fruit flavours make it healthier. (Dr. Javed Khan, 2010) Another factor adding to its popularity is its social acceptability as compared to cigarettes and its portrayal is a symbol of modern lifestyle. Our research has shown that increasing consumption of Shisha smoking among the young generation is likely to become a serious public health issue of Pakistan in a very near future. Research has shown that people who consume Shisha are likely to become regular cigarette smokers and are also pushed towards other drugs indirectly. Lack of knowledge is the main problem due to which treatment induced is ineffective to make people quit water-pipe smoking. The space between knowledge and treatment can be filled by the efforts made by the research authorities. People should be aware of the health threats so the new trend of tobacco smoking causing diseases, addiction and death can be prevented. Our health authorities must take notice of the current situation and put a complete ban on serving `Shisha` at any hotel or restaurant in the country. The electronic and print media must warn the public, particularly the youth, on the serious potential health hazards associated with `Shisha` smoking. (Dr. Javed Khan, 2010)

Research Questions

Primary research question

Hazards of Shisha Smoking among youngsters in Lahore, DHA and Gulberg since last past five years.

Subsidiary questions

1. Do you smoke Shisha? This question was generated to know whether the respondent is a smoker or a non smoker. If someone smokes a Shisha, then what the reason actually was, being peer pressure, surroundings or status symbol. If he doesn't, then what is the reason behind it? 2. Do you think Shisha is harmful for health? This question was generated to find out the general opinion of the public about the health hazards of Shisha. 3. Has Shisha become an addiction for you? This question was asked to find out if quitting Shisha smoking is possible for the respondents. It also enquires to what extent is the respondent dependent on the Shisha availability. 4. In your opinion, what is more harmful for health? Cigarette or Shisha? This question inquires the respondents about the misconception of Shisha being less harmful than a cigarette. It is designed to find out how deep is this misconception enrooted in their minds.

Methodology

Data collection tools consist of a questionnaire and 4 interviews. A sample of 30 pupils was taken, consisting of Shisha smokers and non-Shisha smokers, to fill the questionnaire. Questionnaires were distributed using simple random sampling and snowball sampling. 10 questionnaires were filled in the university and the remaining questionnaires were distributed to random pupils in cafes. Once the data was collected, it was analyzed by the help of Statgraphic. Interviews were conducted from four people, a doctor, and a consumer of Shisha, a supplier and a worker in cafe. The worker's and consumer's interview was held on 20th March 2011 at Mini golf. The supplier's interview was conducted on 28th March 2011 at Cafe Rock, while the doctor's interview was carried out (March, 3, 2011). Analyses of questionnaire and interviews have been included in the discussion.

Analysis of Data and Discussion

Social Significance

Shisha in Pakistan was introduced in the cafe “mini golf” in the liveliest city of this country Lahore in 2000. As years passed away Shisha has become one of the most significant product of get togethers. Shah Sharabeel the owner of mini golf received huge amount of revenue and acknowledgment by the serving of Shisha which attracted other businessmen got an idea to promote their cafes by providing Shisha in their cafes. Now there are more than 200 cafes serving Shisha in the city Lahore this is my own observation. It has become so significant that even in the hotels like “Pearl Continental Hotel” also serve Shisha”. Shisha significance has increased dramatically it is not only served in elite areas like Gulberg but also in lower class areas like Anarkali. It was really surprising for me as a consumer of Shisha when I was attending a wedding ceremony where I was served a Shisha, this was the very moment when I myself gave a thought that Shisha is becoming a part of Lahore's culture. The serving of Shisha in wedding ceremonies is becoming so common nowadays, I myself have attended five wedding ceremonies in which Shisha had been served. Nowadays majority of youngsters have Shisha at their homes this shows that Shisha is now socially accepted as a part of our culture. In the questionnaire I proposed a question in which I asked about their parents strict check on Shisha smoking habit majority reply was no. This shows that people do not consider Shisha as a demerit good as is a cigarette. One of the main reasons for a drastic increase in Shisha consumption is that people have a false assumption that Shisha is environmental friendly and is less harmful than cigarette whereas in a research it has been proven that Shisha is far more dangerous for one's health as compare to cigarette. (See Appendix C, Figure 4). I come to about this false assumption by interviewing a regular consumer of Shisha. While interviewing there was a question raised that why is Shisha becoming so common among youngsters like you? In reply a consumer said that Shisha is becoming a trend among youngsters, people have an incentive to hang out which is to have Shisha. Shisha in short time period had turned out to be a style icon, Shisha's consumers covered people from almost all groups of society. The young people are at top of the list in Shisha's fan club. The attempts of the Punjab Government to check this fast growing culture had raised many questions and the most important is that when cigarette and other drugs are not been checked by the government then why the ban on Shisha? In reply it's simple that Shisha is socially accepted. When people don't get back from trying cigarettes and other drugs then this Shisha a tasty fruitful sweet flavoured smoking system should not be refraining by people. There are many reasons for smoking Shisha some says that it is a hobby, it is the best pastime with friends, a way of keeping up-to-date with newest trends or just puffing as others do it. Shisha consumption is not limited to Shisha bars only but it is spreading its roots in education premises as well, “With the hovering news of Punjab Government's consideration for an altogether complete ban on Shisha, many willing investors feel discouraged to step in the previously blooming Shisha business. Of course a 100 percent ban on anything cannot be deemed possible but even a few effective measures here by the government can lead to a relatively large potential drop in the Shisha market.”(Younis, 2011) Shisha has become so common in Pakistan that nearly all cafes, restaurants and eateries offer Shisha in variety of flavours. “Our young generation today are attracted to Shisha, as it comes in a variety of flavours and is popular as a group activity”. Many Shisha consumers have faith in this false statement that Shisha is less harmful than cigarettes but the reality is quiet different Shisha is far more different than cigarettes. By smoking Shisha one inhales more carbon monoxide as compare to inhaling of cigarettes, which cause heart diseases, respiratory problems and many more similar to cigarettes diseases.” According to a study conducted in Saudi Arabia, where Shisha is very popular, Shisha is just as, if not more, harmful than normal cigarettes. Headaches, blurred vision, palpitations and dizziness are just some of the symptoms reported by Shisha smokers as well as cigarette smokers.”(Mugani, 2009). Government of Pakistan should implement laws against Shisha smoking in public places, as this kinds of laws have been implementing in many countries all over the world. Whereas if someone wants to smoke he/she should does it at his/her home. Government should create awareness especially among young generation by setting awareness programme conducted in educational institutions to educate people about the hazards of Shisha smoking. (Mugani,2009) Shisha smoking for one hour is equal to 100 cigarettes smoking, Shisha addiction has increased in the form of fashion.” Pakistan Chest Society Sindh's General Secretary Dr Mushataque Ahmed Memon informed that a recent research has revealed that smoking Shisha is 10 times more injurious as compared to cigarette while smoking Shisha for an hour is equivalent to smoking 100 cigarettes, adding that the impacts of cigarette smoking are not hidden from anyone.” (Hanif, 2011) General Secretary said that Shisha smoking causes lung cancer. Causes respiratory problems and asthma. In addition it also causes mental health problems. He said that because of non-implication of laws to ban shiha, Shisha has become a vital problem young generation's health, this issue has kept un noticed but it should be considered one of the main problems. “Pakistan Medical Association's President Prof Dr Idrees Edhi said that Shisha is becoming common since families do not consider it bad. He said especially the youth adopt Shisha smoking as a trend which eventually leads to addiction.”(Hanif, 2011) He said that everyone is aware of the hazards of cigarettes but no one is aware of the hazards of Shisha. Every cafe and restaurants serve Shisha where every student whether a boy or a girl both enjoy the taste and smoke of Shisha without noticing its hazards.A  He pointed out certain misconceptions which are the reasons behind this rising trend he said people think that Shisha is environmental friendly due to baseless reasons including that the tobacco is filtered through water before inhalation; less nicotine content than that of a cigarette and healthier smoking due to the addition of fruit flavours but these all are misunderstandings.” Dr Javaid Khan told that he conducted a survey in four universities which revealed that 43 percent male and 11 percent female students were the addicts of Shisha while 60 percent males and 18 percent females had consumed Shisha once in their lives.” (Hanif, 2011). Shisha has become a major part of majority of the youngsters as I carried out a survey in which I asked the quantity of consumption of Shisha on average, majority reply was once daily. Shisha has become more of a trend and a way to keep one up to date. It has become a mean of get together. People even consider it as a best pastime. This really shows its significance. Government carry out surveys, research and passing laws against Shisha shows that Shisha is becoming Pakistanis culture its significance is increasing day by day. Nowadays it is becoming a major part of any festivalA  whether it is basant, jash-ne- bahara, wedding ceremony, birthday party or any private party. Shisha is available almost everywhere as a cigarette is available. People prefer Shisha over cigarettes as they follow their false assumption that Shisha is less harmful than cigarettes. This all major points show that Shisha is affecting our nation by all means. (Hanif, 2011).

Shisha Cafes

In its most common meaning a cafe is a place to eat, a restaurant as we may call it, but when we talk about a cafe in Lahore, Pakistan there is a difference in its meaning than a restaurant. A cafe in Lahore has one distinctive feature than restaurants, which is, it is also a Shisha corner.A Shisha has become a lot popular since it was first introduced, around 10 years ago. The first place where it was served is National Park, more commonly known as Mini Golf. One of its owners is the most popular of personalities of Lahore, Shah Sharabeel. Ali Shisha wala isthe sole manufacturer of a certain design of Shisha. As Shisha increased in demand, investors set in to meet this demand. Places like Defense Housing Authority (DHA) and Gulberg were filled with such cafes. As competition set in, Mini golf managed to hold three open bars for Shisha serving which attracted quite a lot of teenagers, they offered, and still do, different discount cards to attract customers, mainly targeting teenagers, portraying Shisha as the new ‘hip' product. Hazards of Shisha were not much of a concern then. It was only until recently that the hazards of Shisha have become a major concern. As Javed(2010) claims in an article, that Shisha has indeed become an addiction, which is widespread in the 16-25 years age group which consisted of 70 percent males and 30 percent female Shisha smokers. According to our research, most of the Shisha smokers are unaware of the threats posed by it and those who are aware of the hazards do not seem to understand the seriousness of it, like many cigarette smokers. The contents of Shisha mostly carry prohibited and addictive substances. One of the dangers is that Shisha may result into low fertility rates among girls. There may be about 30 cafes in DHA and Gulberg only and by personal experience I know that none of the suppliers were aware of the hazards of Shisha smoking, if they were, they were not concerned by it, but everyday they make much profits through their customers. The Government's consideration of Shisha and its hazards have only recently come into play due to the protests by the media and the DHA Shisha ban phenomenon, which happened about 3 years ago. It is suspected that a lot of malpractice takes place during Shisha sessions. It is precisely that reason why Shisha has been banned outright in DHA. A girl expired while smoking Shisha which contained wine instead of water and cocaine instead of flavor in it, the mixture reacted pretty bad or heavy for the girl's body. However this did not seem to have a substantial effect on Shisha smokers and Shisha providers. However Shisha cafes remain open in the outskirts of DHA, shifting the consumers to these cafes.A When we talk about Shisha hazards and the cafes who are providing it, we seem to forget about the workers of that place. I aimed to fulfill this gap and obtain their views. One of the workers, Muhammad Arslan who works at mini golf, was interviewed. He says that he and he alone serves up to 70 Shishas everyday. When asked about his health he claimed that he has not observed any change in his health. Another waiter standing nearby responded to this question too, stating that he feels addicted to Shisha smoking. However, my personal reviews about Arslan were that his face was pallid and he seemed very weak by his appearance, like a drug addict, to be more accurate. When asked that why did he preferred serving Shisha and not food, his answer was that he always wanted to do this, he states that by checking and listening to his customers' reviews of the Shisha he served, gives him pleasure. Finally we asked him about the safety precautions, the management had to propose to the workers, we received a flat “nothing” as an answer to this. It is agonizing to see how badly these investors treat their workers, who risk their lives to conduct their tasks although they are not aware of it, who are not being paid adequately and no precautions! The workers may not be aware of the hazards of Shisha; it is their employer's responsibility to take notice of their health. Awareness campaigns should be held in order to save these workers. It should be discouraged; the employers ought to take responsibility for their health. If one worker serves up to 70 Shisha on average, this is an outrage that their employers are not even concerned. The government should take notice of this worker exploitation. Once the interview was conducted and analyzed, we shifted towards the suppliers to obtain reviews and their justification of the worker exploitation. We also intend to find whether they are affected by the ban on Shisha in DHA. Since the hovering news of the raid in Jammin Java cafe in Gulberg, many cafes have taken precautions, as the Government seems to take notice on the hazards of Shisha. An example is a notice outside mini golf's Arabian lounge, which said “Shisha will not be served to underage pupil.” Cafe rock was surveyed as a sample and interviewed its owner, Omer Javed Butt. There was also a sign board on its entrance saying the same statement mentioned above. Starting with the obvious of questions was he aware of the danger posed by Shisha. Yes, he does but according to Mr. Butt there are certain flavors which are dangerous for example, Gutka and its mixture with other flavors. He states that his cafe does not cater any such flavors. He claims that his cafe's main purpose is to serve as a restaurant. Their cafe provides Shisha with food only. This is a mean to discourage Shisha, according to him. With this caution they manage to make about RS 300,000 every month, exclusively on Shisha. When asked about what measures have he taken for the workers' health, he states that he has simply reduced their working hours compared to other waiters without any increments in their wage or any other fringe benefits. As for the government's consideration on Shisha, it can't be banned outright because cigarette smoking have not been banned, which is a more dangerous addiction. By pointing out the government's lack of authority in banning cigarette smoking, they intend to de-track the government and compensate them for providing Shisha. And since Shisha have been brought into citizens homes, it simply can't be banned, because it would not stop smokers (Omer, personal communication, 2011, March 28t). The measures taken by the Punjab Government to decrease the consumption of Shisha is have not resulted into a major threat as their business have not been affected by it(Omer, personal communication). The reason for ban on Shisha in DHA is known to everyone, even our interviewees. It has been a rumor that many people and cafes have been infusing drugs in the contents of Shisha. However it have never been proven, neither have anybody witnessed it. While surveying Arslan was inquired about the rumored drug activity taking place in cafes, he disagrees; drug activities are not conducted publicly but in privacy. Furthermore, such activities cannot take place within a cafe's premises as drugs like cocaine can easily be detected (Omer, personal communication, 2011, March 21st). The university grapevine tells a different story, it is known by students that malpractice can take place publicly although not anymore, due to the recent police raid in two cafes. The police forced their way in Sheikhoo's cafe and cafe life on March, 17, 2011, although illegally as they failed to show a warrant when inquired, but when asked from the policemen, they claim that they were conducting raids under orders of the Lahore CCPO (Pakistan today, 2011). Under such circumstances the cafe owners take precautions so as not to damage their reputation in the market. As one can conclude from the results, it is advisable for the government to take actions but legally and in a subtle manner.

Clientele

In Pakistan traditionally used “hookah” is now known as Shisha. Shisha is gaining massive popularity among youth of Lahore, Islamabad and Rawalpindi causing serious health issues to their lives. People addicted to smoking Shisha faces many problems due to its ban. The major concern for the society is the increasing rate of smokers in both male and female. Shisha attracts more customers than cigarettes as it is served with flavours and sweet-smelling substances of Lemon, Strawberry, Orange, Apple, Honey and cherry. Although the ban on the use of Shisha has been "selectively" imposed by the governments in certain areas but violators are not being prosecuted. Some restaurants are still offering Shisha to the teenagers who are visiting these places in increasing numbers. These youngsters seem to have taken Shisha as a style symbol without knowing its consequences (See Appendix C, Figure 1). Shisha smoking is one of the most recent trends among the youth of Lahore. Cafes offering Shisha are considered to be ‘in' and therefore, gain a big “clientele”. According to a newspaper report, Lahore's Defence Housing Authority (DHA) has asked cafes not to serve Shisha as it is injurious to health and also used in the consumption of drugs in most of the cases. Concerned parents feel relaxed after the imposition of ban on Shisha. However, there are still many questions unanswered such as “Do we have definitive medical evidence suggesting that smoking Shisha is a health hazard? Do cafes need official permission for serving Shisha? Why is it still being allowed to be served in other parts of Lahore?” (“Lahore's bifurcated laws - the perils of smoking Shisha in DHA”, 2008). Government and NGO's should work in collaboration to find concrete evidence regarding the harmful effects of Shisha and hence, issue health warnings to youngsters as it was done in case of cigarette smokers. If Shisha is considered to be harmful, it has to be banned all over the city. It makes no sense why the administration outside DHA is not asked to impose a ban on it. (2008) Young people are the primary target of the tobacco industry in Pakistan. In order to create 100 percent smoke-free environment complete ban should be imposed on tobacco advertising. Similarly to discourage its use tobacco taxation should be introduced. As we all know that youth is the backbone of every nation. In order to maximize their profits tobacco industry needs to replace people who quit smoking with new young customers. This can only be done by attracting more individuals from worldwide with potentially divesting health consequences. Some people thing that smoking Shisha is less injurious to health than smoking cigarettes however, they both cause serious diseases such as lung cancer. (Maqbool, 2009). According to Section-8 of the Prohibition of Smoking and Protection of Non-smokers health ordinance, in year 2002 no person was allowed to sell tobacco products to any other person under the age of 18 years as it was against the law. The enforcement of this section of law has remained weak so far. (Maqbool, 2010). The National Bank Park near Kalma Chowk and restaurants around Gaddafi stadium are identified as hubs of Shisha smoking. Chief Minister Shahbaz Sharif took action in the Senate and standing Committee on health to stop the trend of Shisha bars in high-class and middle class areas making teenagers especially women addicted. He promised that no new contracts will be issued to Shisha bars in parks to stop unhealthy activities in young generation. (“25pc people may be diabetic by 2025”, 2010). Another important thing is parents generally do not know that flavored tobacco used in Shisha is as dangerous as cigarettes tobacco. Due to which TCC (Tobacco Control Cell) has printed flyers to distribute them in the educational institute to highlight the dangers of Shisha smoking and the fact that it is against the law to serve Shisha to those who are under 18 years of age. (Maqbool, 2011). According to Muhammad Ahmed Pansota a police team led by the Liberty police SHO raided Restaurants of Danial Arif (Sheikhoo's Cafe at MM Alam Road), and Arif Saleem (Cafe Life at Gaddafi Stadium). There were two Shishas held from Arif's restaurant and four from Saleem's. The police told them that were not allowed to serve Shishas, though the police had nothing in written. The petitioners' added they serve Shisha throughout the province without any opposition from the government officials. The clients were not implicated in any criminal activities rather the police raid was unlawful and meant to blackmail them to close their business. The clients were aware of all the rules and regulation regarding their business. The police raid not only damaged the petitioners' reputation but also resulted in great loss Pansota added. The court has been requested to declare this action of police illegal and unlawful. (“Shisha ban: Police chief summoned over restaurant”, 2011). Habiba Younis points out that Shisha initially emerged as a style icon in “elite circles” has now covered people from nearly all groups of society. The most prone of these were, of course, young people. For many it was a hobby, a past time with friends, a mean of being advanced with the latest trends or simple leisure puffing just because others are doing it. Moreover, nowadays its usage isn't only confined to Shisha bars but it is also growing roots in educational premises such as universities. It isn't rare to find students using their own water pipes in university corners and hostels. Also a fact worth mentioning here is that under the cover of Shisha tradition many other drugs are now available in the market. Many bars have been reported to serve Shisha mixed with illegal drugs like heroine and hashish. (2011). Shisha is not that harmful as cigarettes are. They include natural flavors which are environment friendly. It gives out less CO as compared to cigarettes. Smoking twice a day makes it easy to quit smoking cigarettes. It is the best substitute, as it is becoming popular among youth. (U. M. Gondal, personal communication, March, 20, 2011). WHO (World Health Organization) the TCC of the ministry of health has produced a 15-minute video to draw attention to tobacco control laws and their enforcement in Pakistan. The documentary discusses the Shisha among youth and the prohibitation of sale of tobacco products to youth. Shisha has become a style symbol and youth are using it without realizing its impact on health. (“Pakistan produces first-ever video on tobacco, 2011). CPO Ghulam Mehmood Dogar says while talking to delegations of students and teachers that young generation is spoiled due to economic disparity and they are a subject to sexual abuse. It is termed as a tragedy of the society. The police are therefore, ordered to launch crackdown soon against drug trafficking, internet cafes and Shisha smoking. (“Crackdown against mini cinemas on the cards, 2011). According to a survey there are nearly 30 million smokers in the country. Almost 100,000 deaths every year are related to smoking diseases. Over 85 percent of the cases of lung and mouth cancer and asthma are smoker. Pakistanis spend over Rs50 billion annually on smoking. The Anti Narcotic Force document says one hour smoking of Shisha is more harmful than smoking of 100 cigarettes. (Ahmad, 2011). Similarly it is stated that, the ratio between young male and young female smokers had shrunk from 4:1 in 1996 to 2:1 in 2003. It is alarming to note that Shisha smokers are budding in numbers, due to certain traditions attached to it made it more popular among the youth today.A  There is an urgent need to educate the public against the dangers of the Shisha use. (“Tabacco kills 274 Pakistanis every day: experts”) According to a social worker Munir Khan who visited more than 5 Shisha Houses in Model Town, Johar Town, Tech Society, DHA and M M Alam road Gulberg told this scribe that he talked to a group of teen-agers sitting in a Shisha House and they told him that their parents were unaware about water pipe smoking habit and if they knew, they would have no objection, he added (Butt, 2009). After we circulated self-administered questionnaire, deduced results states that even though, Shisha is harmful to health majority of people do not want it be banned. (Appendix A)

Health Issues

Shisha smoking has quite various gangerous effects on a man's health. The increasing trend of Shisha smoking observed in the last few years is mostly due to the misconceptions regarding its use, for instance that nicotine content is lower than that of cigarettes and that water filters out all the toxic chemicals including carbon monoxide (CO), nicotine and tar. New research has suggested that the water pipes have three additional lethal risks over cigarette smoking.

1. Flavored tobacco is smoked over coals and fumes from these fuels add new toxins to the already dangerous smoke;
2. Shisha smokers inhale up to 200 times more smoke in a single Shisha session than from a cigarette;
3. And its social acceptance has resulted in high levels of secondhand smoke. (Our literature review)

Smoke from the Shisha contains hundreds of potentially dangerous heavy metals like, Arsenic, Cobalt, nicotine, coaltar, Carbon Monoxide (CO), Lead and Chromium.A  Research has shown that under normal Shisha use the smoke produced from a single pipe use contain approximately the same amount of Nicotine and Tar equivalent to 20 Cigarettes. Research has also shown that after 45 minutes of Shisha use expired air, carbon monoxide, plasma nicotine and heart rate are significantly elevated. While research about Shisha smoking is still emerging, evidence shows that it poses many dangers:

• Shisha smoke contains high levels of toxic compounds, including nicotine, tar, carbon monoxide, heavy metals and cancer-causing chemicals (carcinogens). In fact, Shisha smokers are exposed to more carbon monoxide and smoke than are cigarette smokers.
• As with cigarette smoking, Shisha smoking is linked to lung and oral cancers, heart disease and other serious illnesses.
• Shisha smoking delivers about the same amount of nicotine as cigarette smoking does, possibly leading to tobacco dependence.
• Shisha smoke poses dangers associated with secondhand smoke (CO).
• Shisha smoking by pregnant women can result in low birth weight babies. Young female smokers are often motivated more by the desire to “stay thin” or “look cool” than to avoid an illness in middle life.
• Shisha pipes used in Shisha bars and cafes may not be cleaned properly, risking the spread of infectious diseases (T.B, Herpes, Hepatitis).

The purpose of this research paper is to create awareness among the youth about the toxic substances present in the smoke of Shisha and the dangerous health hazarards caused due to them. Large number of the people who smoke Shisha are addicted to its taste as it is served with aromatic flavours. (Appendix C, Figure 3). Tobacco also containsnicotine, which according to a Medical Officer Dr. Hassan Tariq at Adil Hospital, Lahore, is a highly addictivepsychoactivechemical. Nicotine dependence may also result from repeated inhalation of tobacco smoke from Shisha. When tobacco is smoked, nicotine causes physical and psychological dependency. In some people, using any amount of tobacco can quickly lead to nicotine dependence. Nicotine dependence according to a reliable search source, ‘www.mayoclinic.com', is an addiction to tobacco products caused by the drug nicotine. Nicotine dependence — also referred to as tobacco dependence — means you can't stop using the substance, even though it's causing you harm. While it's the nicotine in tobacco that causes nicotine dependence, the toxic effects come mainly from other substances in tobacco. Smokers have much higher rates of heart disease, stroke and cancer than do nonsmokers. (“Nicotine dependence”, 2010) During the research, various visits were made to different restaurants and cafes, and it was found out that consumers fell a sense of pleasure during Shisha smoking. Nicotine produces physical and mood-altering effects in your brain that are temporarily pleasing. These effects make you want to use tobacco and lead to dependence. At the same time, stopping tobacco use causes withdrawal symptoms, including irritability and anxiety. (Wikipedia) Many individuals bolster their denial of harmful effects of Shisha smoking by focusing on someone they know personally who smoked until he or she was very old and died peacefully in bed. Such strong counter example helps smokers to maintain internal beliefs that comfort them when presented with statistical evidence. Many effective treatments for nicotine dependence are available to help you manage withdrawal and stop smoking for good. Signs that you may be addicted include:

• You can't stop smoking.You've made one or more serious, but unsuccessful, attempts to stop.
• You experience withdrawal symptoms when you try to stop. Your attempts at stopping have caused mood-related signs and symptoms, such as strong cravings, anxiety, irritability, restlessness, depressed mood, frustration or anger, difficulty concentrating, increased hunger, insomnia, and or diarrhea constipation.
• You keep smoking despite health problems.Even though you've developed problems with your lungs or your heart, you haven't stopped or can't stop.
• You give up social or recreational activities in order to smoke.You may stop going to smoke-free restaurants or stop socializing with certain family members or friends because you can't smoke in these locations or situations.

Shisha contains Carbon Monoxide (CO) which produces certain harmful diseases such as Chronic obstructive pulmonary disease(COPD), also known aschronic obstructive lung disease(COLD),chronic obstructive airway disease(COAD),chronic airflow limitation(CAL) andchronic obstructive respiratory disease(CORD), which is the co-occurrence of chronic bronchitisandemphysema, a pair of commonly co-existing diseases of the lungs in which theairwaysbecome narrowed. (U.S. National Heart Lung and Blood Institute - What is COPD).This leads to a limitation of the flow of air to and from the lungs, causingshortness of breath. In clinical practice, COPD is defined by its characteristically low airflow onlung function tests.In contrast toasthma, this limitation is poorly reversible and usually gets progressively worse over time. COPD is caused by noxious particles or gas, most commonly fromtobacco smoking, which triggers an abnormalinflammatory responsein the lung. (Rabe KF, Hurd S, Anzueto A,et al.,2007).The inflammatory response in the larger airways is known aschronic bronchitis, which is diagnosed clinically when people regularly cough upsputum. In thealveoli, the inflammatory response causes destruction of the tissues of the lung, a process known as emphysema. The natural course of COPD is characterized by occasional sudden worsening of symptoms called acute exacerbations, most of which are caused byinfectionsorair pollution. One of the most common symptoms of COPD is shortness of breath (dyspnea). People with COPD commonly describe this as: "My breathing requires effort," "I feel out of breath," or "I can't get enough air in".People with COPD, typically first notice dyspnea during vigorous exercise when the demand on the lungs is greatest. Over the years, dyspnea tends to get gradually worse so that it can occur during milder, everyday activities such as housework. In the advanced stages of COPD, dyspnea can become so bad that it occurs during rest and is constantly present. Other symptoms of COPD are a persistent cough,sputumor mucus production,wheezing, chest tightness, and tiredness. People with advanced (very severe) COPD sometimes developrespiratory failure. When this happens,cyanosis, a bluish discoloration of the lips caused by a lack of oxygen in the blood, can occur. An excess of carbon dioxide in the blood can cause headaches, drowsiness or twitching (asterixis). A complication of advanced COPD iscor pulmonale, a strain on the heart due to the extra work required by the heart to pump blood through the affected lungs. There are a fewsignsof COPD that a healthcare worker may detect although they can be seen in other diseases. Some people have COPD and have none of these signs. Common signs are:

• tachypnea, a rapid breathing rate,
• wheezing sounds or crackles in the lungs heard through astethoscope,
• breathing out taking a longer time than breathing in,
• enlargement of the chest, particularly the front-to-back distance (hyper aeration),
• active use of muscles in the neck to help with breathing,
• breathing through pursed lips,
• increased antero posterior to lateral ratio of the chest (i.e.barrel chest).

CO is also a cause of Chronic Bronchitis. Lung damage and inflammation in the large airways results in chronic bronchitis. Chronic bronchitis is defined in clinical terms as a cough withsputumproduction on most days for 3 months of a year, for 2 consecutive years. In the airways of the lung, the hallmark of chronic bronchitis is an increased number (hyperplasia) and increased size (hypertrophy) of the goblet cellsandmucous glandsof the airway. As a result, there is more mucus than usual in the airways, contributing to narrowing of the airways and causing a cough with sputum. Microscopicallythere isinfiltrationof the airway walls withinflammatorycells. Inflammation is followed by scarring and remodeling that thickens the walls and also results in narrowing of the airways. As chronic bronchitis progresses, there issquamous metaplasia(an abnormal change in the tissue lining the inside of the airway) andfibrosis(further thickening and scarring of the airway wall). The consequence of these changes is a limitation of airflow. (“Chronic obstructive pulmonary disease”, 2011) Patients with advanced COPD that have primarily chronic bronchitis rather than emphysema were commonly referred to as "Blue Bloaters" because of the bluish color of the skin and lips (cyanosis) seen in them.Thehypoxiaandfluid retentionleads to them being called "Blue Bloaters". (Longmore, J. M.; Murray Longmore; Wilkinson, Ian; Supraj R. Rajagopalan, 2004) Emphysema is also caused due to the presence of CO which is an important ingredient of Shisha smoke. Lung damage and inflammation of the air sacs (alveoli) results in emphysema.Emphysemais defined as enlargement of the air spacesdistalto theterminal bronchioles, with destruction of their walls.The destruction of air space walls reduces thesurface areaavailable for the exchange of oxygen andcarbon dioxideduring breathing. It also reduces the elasticity of the lung itself, which results in a loss of support for the airways that are embedded in the lung. These airways are more likely to collapse causing further limitation to airflow. The effort made by patients suffering from emphysema during exhalation, causes a pink color in their faces, hence the term commonly used to refer to them, "Pink Puffers". (“Chronic obstructive pulmonary disease”, 2011) Epidemiologicalstudies show that non-smokers exposed to secondhand smoke are at risk for many of the health problems associated with direct smoking. During the interview with a doctor, it was a shocking fact to find out that Shisha smoking not only affects the direct smoker but also affects the people around him in a rather worse manner. This phenomenon is called Passive smoking whichis the inhalation of smoke, calledsecondhand smoke(SHS) orenvironmental tobacco smoke(ETS), fromtobacco products used by others. It occurs when smoke permeates any environment, causing its inhalation by people within that environment. Scientific evidence shows that exposure to secondhand tobacco smokecausesdisease, disability, and death. Currently, the health risks of secondhand smoke are a matter ofscientific consensus, and these risks have been one of the major motivations forsmoking bansin workplaces and indoor public places, includingrestaurants and cafes etc. (“Passive smoking”, 2011) In 1992, theJournal of the American Medical Associationpublished a review of available evidence on the relationship between secondhand smoke and heart disease, and estimated that passive smoking was responsible for 35,000 to 40,000 deaths per year in theUnited Statesin the early 1980s.Theabsolute risk increaseof heart disease due to ETS was 2.2%, while theattributable risk percentwas 23%. Research using more exact measures of secondhand smoke exposure suggests that risks to nonsmokers may be even greater than this estimate. A British study reported that exposure to secondhand smoke increases the risk of heart disease among non-smokers by as much as 60%, similar to light smoking.Evidence also shows that inhaled side stream smoke, the main component of secondhand smoke, is about four times more toxic than mainstream smoke, a fact that was known to the tobacco industry since the 1980s, which kept its findings secret. Some scientists believe that the risk of passive smoking, in particular the risk of developing coronary heart diseases, may have been substantially underestimated. A minority of epidemiologists find it hard to understand how environmental tobacco smoke, which is far more dilute than actively inhaled smoke, could have an effect that is such a large fraction of the added risk of coronary heart disease among active smokers.One proposed explanation is that secondhand smoke is not simply a diluted version of "mainstream" smoke, but has a different composition with more toxic substances per gram of total particulate matter.Passive smoking appears to be capable of precipitating the acute manifestations of cardio-vascular diseases (atherothrombosis) and may also have a negative impact on the outcome of patients who suffer acute coronary syndromes. Raupach T, SchA¤fer K, Konstantinides S and Andreas S (2006). "Secondhand smoke as an acute threat for the cardiovascular system: a change in paradigm".(European Heart Journal,27, 4, pp.386-392). According to a local gynecologist, Dr. Sobia Nadeem, tobacco use in women is also an important factor in miscarriages among pregnant Shisha smokers, it contributes to a number of other health threats to the health of the fetus such as and low birth weight premature births and increases by 1.4 to 3 times the chance forSudden Infant Death Syndrome (SIDS).To strengthen this fact with the hlp of an evidence, it is stated that result of scientific studies done in neonatal rats seems to indicate that exposure to cigarette smoke in the womb may reduce the fetal brain's ability to recognizehypoxicconditions, thus increasing the chance of accidentaldeath. It was also found out that incidence ofimpotencyis approximately 85 percent higher in male smokers compared to non-smokers. (Dr. Hassan Tariq, Adil Hospital, Lahore) There is also some evidence that Shisha use may also decrease the sperm count in men. Children are particularly vulnerable to the harmful effect of the Shisha use (Dr. Javed Khan, Aga Khan University Hospital, Karachi). Much like cigarette smoke, Shisha smoke can lead to heath problems such as lung disease, emphysema, asthma, low birth weight and cancer of the mouth, esophagus and lungs. According to Professor Javaid Khan of Aga Khan University in Pakistan, "regular Shisha users have lung functions approximately 25 percent lower than those who do not use this." Professor Khan also notes that children are especially susceptible to harmful effects such as lung infections, asthma and sudden infant death syndrome. (Gream, 2010). Smoking Shisha dramatically increase the risk of developing many diseases .It is responsible for a substantial majority of cases of lung cancer, oral cancer and chronic obstructive pulmonary disease, and most smokers die either from these respiratory diseases or from ischemic heart disease. Smoking also causes cancers to the upper respiratory and gastrointestinal tracts, pancreas, bladder and kidney and increase ricks of peptic ulceration. Authracsis (black lung) is coal induced pulmonary leisan in tobacco smokers. Inhaled carbon pigment is engulfed by alveolar macroplges which then accumulate in connective tissue along with lympleatices. Smoke from a Shisha is also a major cause of oral cancer. Cancer is defined as the uncontrollable growth of cells that invade and cause damage to surrounding tissue. Oral cancer appears as a growth or sore that does not go away. (Wikipedia) If you notice any of these changes, contact your dentist immediately for a professional examination which includes cancers of the lips, tongue, cheek, floor of the mouth, hard and soft palate, sinuses, and pharynx (throat) — can be life-threatening if not diagnosed and treated early. The following are the common symptoms:

• Swellings/thickenings, lumps or bumps, rough spots/crusts/or eroded areas on the lips, gums, or other areas inside the mouth,
• The development of velvety white, red, or speckled (white and red) patches in the mouth,
• Unexplained bleeding in the mouth,
• Unexplained numbness, loss of feeling, or pain/tenderness in any area of the face, mouth, or neck,
• Persistent sores on the face, neck, or mouth that bleed easily and do not heal within two weeks,
• A soreness or feeling that something is caught in the back of the throat,
• Difficulty chewing or swallowing, speaking, or moving the jaw or tongue,
• Hoarseness, chronic sore throat, or changes in the voice
• A change in the way your teeth or dentures fit together - a change in your "bite",

The MO at Adil Hospital, Lahore also told that Sore throat is also caused to the consumption of Shisha. Sore throat is pain, scratchiness or irritation of the throat that often worsens when you swallow. A sore throat is the primary symptom of pharyngitis which is inflammation of the pharynx, or throat. But the terms "sore throat" and "pharyngitis" are often used interchangeably. Symptoms of a sore throat may vary depending on the cause. Signs and symptoms may include:

• Pain or a scratchy sensation in the throat,
• Pain that worsens with swallowing or talking,
• Difficulty swallowing,
• Dry throat,
• Sore, swollen glands in your neck or jaw,
• Swollen, red tonsils,
• White patches or pus on your tonsils,
• Hoarse or muffled voice,
• Refusal to eat (infants and toddlers). (“Sore throat”, 2010)

According to some respondents, Sinus headaches are also experienced due to the smoke. These are headaches that may accompany sinusitis, a condition in which the membranes lining your sinuses become swollen and inflamed. You may feel pressure around your eyes, cheeks and forehead. Perhaps your head throbs. Although these can indicate sinus headaches, don't jump to conclusions. Many people who assume they have sinus headaches actually have migraines or tension headaches. When sinus headaches caused by sinusitis do occur, proper diagnosis and treatment are the keys to relief. While doing this research, we came across a notion that a one hour session of Shisha smoking is equivalent to 100 cigarettes. While interviewing a doctor at Adil Hospital, Lahore, it was shocking to come across the fact that even the doctor agreed to this fact which previously just seemed like a notion. According to a House Officer Dr. Hassan Tariq at Adil Hospital, Lahore, the tobacco is no less toxic in a Shisha pipe, and the water in the Shisha does not filter out the toxic ingredients in the tobacco smoke. When asked the question if one hour ofA  Shisha smoking is equivalent to 100 cigarettes, he told us that Shisha smokers may actually inhale more tobacco smoke than cigarette smokers do because of the large volume of smoke they inhale in one smoking session, which can last as long as 45 minutes. “Shisha has dangerous effects on the body because it exposes the smoker to a much larger volume of smoke than what would be inhaled from a cigarette. Even though the smoke is filtered out by water, inhalation of toxic substances is similar to or even greater than that of cigarette smoking. Many people are misled in believing that water filters out the toxins and that nicotine is reduced in water pipe smoking. Not only does water pipe smoking include the same substances as cigarette smoke such as carbon monoxide and tar, tobacco used for water pipe smoking contains two to four percent nicotine, as opposed to the one to three percent for cigarettes,” Krebs said. “The pressures of work and emotional stress of people who feel they do not live their lives well create tension and psychological pain,” he said. “They want to stop this pain, so they decide to smoke Shisha, which has chemical sedatives that are absorbed in the lungs.A  Those sedative chemicals travel through the blood to anesthetic centers in the brain, causing people to relax somewhat,” al-Khamery said. A single session of smoking Shisha produces carbon monoxide levels four to five times higher than those produced from smoking a cigarette. When the breath of heavy tobacco smokers was measured, carbon monoxide levels of 30 to 40 ppm (parts per million) were found. These levels indicate that approximately 5 to 7 percent of blood was not functioning properly. The breath of Shisha smokers measured 40 to 70 ppm of carbon monoxide, resulting in 8 to 12 percent of blood being affected. BBC News notes that the normal carbon monoxide level is 3 ppm. Elevated carbon monoxide levels can result in brain damage and unconsciousness. Though not a risk directly associated with Shisha, the spread of infectious disease is associated with shared water pipes. Saliva transferred from an infected person to a non-infected person via an unclean hose can spread dangerous infectious diseases, such as tuberculosis, herpes and the H1N1 virus, as well as more common illnesses such as the cold and flu viruses. Even if a Shisha smoker decides to quit there are a variety of influences in the wider environment that reduces the chances of sustained success, including peer pressure, Shisha advertisement and finding oneself in circumstances where one previously smoked.

Conclusion

In conclusion, Shisha is more a matter of drugs being involved and steps should be taken to stop it as a means of taking drugs “legally”, thanks to the social acceptance of Shisha. The government should start taking steps in a more subtle manner so as not to give the suppliers a chance to protest, for example, the government can also take steps to ensure that Shisha and cigarettes are not sold to people under the age of 18. Furthermore, like cigarette smoking, Shisha also falls into the grey area where freedom to use it cannot be prohibited in “adults” but steps can be taken by the government to ensure that people are aware of the dangers of smoking Shisha. Apart from awareness campaigns the government can also levy a handsome tax hence, discouraging the use of Shisha and ensuring that most, if not all of the general public, can live a safe and healthy life. As for the workers, the government should inquire the suppliers about their safety precautions, and can pass out a law to ensure the health of workers. According to Habiba Younis policymakers should act “intelligently” to deal with this problem. Strict action should be taken, instead of imposing complete ban on it. “Heavy taxation”, “official checks” and “certain restriction on Shisha” will help to overcome this growing trend among youth. The need of the hour is to formulate strategies that grip this culture. “Although a 100 per cent ban on anything cannot be deemed possible, even a few effective measures here by the government can lead to a relatively large potential drop in the Shisha market.” (2011).

Recommendations

According to this research carried out, it was found that the young generation is heavily getting dependent on the Shisha ignorant of the health hazards it causes. This is mainly due to the fact that in Pakistan and particularly in Lahore, Shisha came into the scenario only six to seven years back in 2006. Therefore, there's not much research carried out in Pakistan regarding Shisha consumption. There is an urgent need to educate the public against the dangers of the Shisha use.A  Our religious scholars as well as non-governmental organizations should come forward and educate the public against the Shisha epidemic which is rapidly spreading in not only in the Muslims countries but also in the developed world. Special seminars should be held in schools across Lahore, warning the children against the dangers of Shisha use.A  Government must also bring laws restricting restaurants owners serving Shisha to its customers. The government ought to conduct investigations in order to avoid any further worker exploitation. The workers have a right to work under safe and healthy conditions. It is not only government's responsibility to discourage Shisha smoking but also the youth. Campaigns in universities should be held in order to increase awareness of the hazards of Shisha. Shisha is not only about the dangers of its ingredients but also the malpractice done using it. It can be very dangerous when one mixes drugs in Shisha. Therefore sale of Shisha should be discouraged at every tobacco shop.

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