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.

We have divided our main research topic into 5 different domains.

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..  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.  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 festival  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. 

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. 

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