The Impact of Hookah on the East-African Community

by: Zahra Bashir - Community Health Worker

WellShare International youth on KIck (cigarette) Butts Day

WellShare International youth on KIck (cigarette) Butts Day

Hookah use in the East African community

What is Hookah (Shiisha)?

A hookah is a water pipe used to smoke flavored tobacco as well as other types of sweetened tobacco. The origins of the hookah pipe are deeply rooted in ancient Indian and Middle Eastern cultures. However, as those cultures began to influence East African countries, the pipe became widely used by Somali and Oromo communities. 

How Does Hookah Work?

The hookah water pipe has a tobacco chamber—what people refer to as the ‘head’—that sits on top of the device. The ‘head’ connects to a pipe leading to a bottom chamber holding the water. An aerated piece of aluminum foil covers the tobacco and pieces of lit charcoal sit atop the foil. The hose used to smoke extends from the side of the pipe; multiple hoses can be attached depending on the pipe design. This allows multiple people to smoke from the same pipe at the same time.

Hookah smoke is highly addictive and contains many of the same toxins as cigarettes. A common misconception is that the water in the pipe filters some of these toxins out. On the contrary, hookah smoke contains harmful chemicals including:

  • Tar

  • Carbon Monoxide

  • Arsenic

  • Lead

  • Nickel

  • Cobalt

The Growing Popularity of Hookah

Hookah smoking has gained a lot of popularity among young people, but particularly young East Africans. A UMN study1 on attitudes and behaviors towards hookah showed that Somali and Oromo young adults and elders believe that hookah smoking is less harmful than cigarette use, ultimately making it more acceptable. 

Results from listening circles conducted by the aforementioned study found the following to be true:

  • Hookah smoking is normative and prevalent among East African family and friends.

  • Socially, hookah smoking in ‘hookah bars’ is very popular and increasing in popularity.

  • Peer pressure heavily influences hookah-smoking culture and non-smokers end up feeling ‘left out’.

  • Second-hand smoke exposure from hookah is not perceived as dangerous.

  • Parents are less concerned about hookah smoke than cigarettes; hookah is more culturally permissible than cigarettes.

  • Generally, wide agreement exists in Islam that mind-altering substances are not acceptable for any gender. It is more culturally acceptable for men to smoke hookah.

  • More men use hookah outside the home in hookah lounges while more women smoke hookah at home.

Health Concerns Related to Hookah

  • Hookah smoking poses the same health concerns that exist for users of other forms of tobacco. The water pipe smoke contains many toxins that can cause various cancers, cardiovascular disease, as well as decreased lung function and fertility.

  • Second-hand smoke dangers are also high with hookah use. Being in the same room with a lit hookah pipe will expose a person to the same cancer-causing toxicants as the smoker.

  • Hookah users are highly susceptible to catching infectious diseases (colds, oral herpes) due to sharing hookah mouthpieces in social settings.

  • In a one-hour session, hookah smokers are exposed to 100 to 200 times the volume of smoke inhaled from a single cigarette.

  • Babies born to hookah smokers weigh at least 3.5 ounces less than babies born to non-smokers.

Recommendations for Physicians

Minnesota has the largest Somali population in the United States. Currently, there are more than 70,000 Somalis residing in the state. In Minnesota, the estimated smoking prevalence among Somalis (24%) is higher than estimates for Minnesota adults (14.4%). Hookah is the second most commonly used tobacco product after cigarettes.

  • Document tobacco use status consistently at each visit and differentiate between traditional cigarettes and hookah use. Preface tobacco use status questions as mandatory, as some Somalis take offense if asked tobacco use status questions by a Somali health care provider.

  • Incorporate aspects of Somali culture by collaborating with local organizations that work with the population. Somali culture places a strong emphasis on family, friends, and a sense of community. Reach out to youth and include religious leaders like Imams to educate people during religious services.

  • Strengthen and support individual willpower. Somali smokers are more likely to quit “cold turkey” and be successful, than go through gradual cessation programs. Some will consider cessation medication like nicotine replacement therapy.

  • Hold Somali women-led and women-only support groups via local organizations that work with the population. There is a lot of underreporting of tobacco use among Somali women due to social stigma. Ensure a high-level of confidentiality for women participants; incorporate “tea and talk;” and be very discreet. Advocate for healthier pastimes like walking or working out together.

  • Link with organizations that create free oral and visual resources in Somali (e.g., videos for clinic TVs, radio programs, Somali messages recorded on clinic hotlines).

For more information, see WellShare International’s tobacco resource page where you can find free educational material on tobacco and hookah use.



The Minnesota Quitline Network Is Here

The Minnesota Quitline Network is now live and active. Formerly the Call It Quits program, the Quitline Network enables health professionals and community organizations to use a single form and fax number to refer the people they serve to tobacco quitline support. This new referral system will allow providers to make the first contact with people who want to quit using tobacco products. The Minnesota Quitline Network is free and open to all Minnesota residents, regardless of health insurance status.


Big Wins in Local Policy

The past few weeks have been exciting for local policy, as Minnesota is now up to 9 cities that have restricted tobacco sales through Tobacco 21. The newest cities to adopt Tobacco 21 are Falcon Heights, Minneapolis, Shoreview, and St. Peter. Another big success is that Falcon Heights restricted all flavored tobacco, including menthol, to adult-only stores, while Mendota Heights restricted all flavors, excluding menthol.


2018 Legislative Summary

The 2018 legislative session saw some great progress towards policies to increase the tobacco age to 21 (Tobacco 21), and to gain long-term funding for smoking cessation services when QUITPLAN Services end. Unfortunately, the legislature did not hear the Tobacco 21 bill despite support from both Democrat and Republican lawmakers. However, while Tobacco 21 has not been considered at the state level thus far, nine Minnesota cities have raised the tobacco age to 21 in the last year. Additional cities are also considering adopting Tobacco 21 policies as well.

Another concern is funding for cessation services as QUITPLAN Services will end in 2020. The state did not allocate any of the $840+ million in tobacco taxes collected in 2017 to cessation services. However, while these policies have not moved forward at the state level, the bipartisan support that Tobacco 21 and cessation funding enjoys is promising for future changes. Tobacco use is Minnesota's leading cause of preventable death and disease, and these policies will help to improve health and save Minnesotan lives.

Lastly, the Physician Advocacy Network wants to extend a huge thank-you to the hundreds of physicians, students, and health care professionals that have supported these efforts during this legislative session. Your efforts make a huge difference!

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Tobacco Cessation Bill Advances at the Legislature

A bill that would dedicate funding to create a tobacco cessation program under Minnesota's Department of Health recently passed the House Health and Human Services Reform Committee with bipartisan support. This bill is critical because QUITPLAN Services, which currently provides free quit-smoking phone counseling and medication to Minnesotans statewide, will close down in March of 2020. Over 150 physicians, medical students and other health care providers have already taken action to let their legislators know they support this life saving legislation. Join them by signing our online postcard today.

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Tobacco 21 Bill Introduced in Minnesota House of Representatives

A bipartisan group of legislators introduce a bill in the House to raise the tobacco sales age to 21 in Minnesota. The bill’s main author, Representative Anselmo (R-Edina) spoke at a press conference alongside TCMS Board Member Dr. Caleb Schultz and other advocates, including youth and members of the Minnesotans for a Smoke-Free Generation coalition. Dr. Schultz was a leader in bringing Tobacco 21 to Edina, the first city to pass the policy last year. He expressed hopes that legislators would support a statewide policy so that all communities can benefit from the lifesaving measure. Bloomington, Plymouth, St. Louis Park and North Mankato have all passed Tobacco 21 policies in the past year. To learn more visit or sign an online postcard to your legislators.


MN Youth Tobacco Use Increases for the First Time in 17 Years

A new survey shows for the first time since 2000, overall youth tobacco use has increased in Minnesota, with 26% of high school students using some form of tobacco or nicotine, up from 24% percent in 2014. This increase is mostly driven by the rapid uptake of e-cigarettes and other vaping devices. The new data show one in five high school students use e-cigarettes, a nearly 50% increase since the data were last collected in 2014. The survey also revealed that over 60% of students who use tobacco report using menthol or other flavored tobacco products. 

The Physician Advocacy Network's Medical Director Dr. Pete Dehnel spoke at a press conference revealing the new data. "Research has found that even in small doses, nicotine exposure in adolescence causes long-lasting changes in brain development, which can have negative implications for adolescents’ learning, memory, attention, and behavior," said Dr. Dehenl. "No amount of nicotine is safe for children and youth." Learn more from the Minnesota Department of Health


Enhanced QUITPLAN® Helpline Services for People with Mental Illnesses and/or Substance Use Disorders

QUITPLAN Services recognizes that individuals with a history of mental illness and/or substance use disorders smoke at higher rates than the general population, smoke more cigarettes per day, and may be at greater risk of negative health effects as a result. To address these concerns, QUITPLAN Services offers a new treatment approach for participants who report one or more mental health conditions. With this new service offering, we hope to help QUITPLAN Helpline participants successfully quit and experience improved health outcomes. 

Enhanced Services
The enhanced services offer: 

  • 7 coaching calls to provide additional support during all phases of quitting. 
  • 12-week regimen of combination Nicotine Replacement Therapy (for age 18 and over) 
  • Communication with the participant’s health care provider with tips for the provider to help support the participant in quitting.
  • A team of specially trained coaches. 

The QUITPLAN Helpline (telephone counseling) is available to uninsured and underinsured Minnesotans. All Minnesotans have access to telephone counseling through their health plan or QUITPLAN Services. 

For more information, contact Randi Lachter, Senior Cessation Manager, ClearWay Minnesota at  You can also find helpful information about tobacco cessation health coverage in Minnesota from the American Lung Association's fact sheet

Have You Looked Upstream Lately?

On January 11th, TCMS's Physician Advocacy Network hosted an event called "Have You Looked Upstream Lately" for medical students at the University of Minnesota. The event highlighted the power of physician advocacy in advancing public health and featured local physician and medical student advocates as presenters. Caleb Schultz, MD, MPH, discussed how he led Edina to become the first city in Minnesota to adopt a Tobacco 21 policy, and medical students Alex Feng and Dave Bergstrand shared their experiences advocating for menthol tobacco restrictions in Minneapolis and St. Paul. If you'd like to learn more about becoming an advocate, contact Grace Higgins at


American Indians in Minnesota Reclaiming Traditional Tobacco


The Star Tribune recently reported on the work American Indians are doing in Minnesota to reduce the use of commercial tobacco and increase understanding of sacred tobacco. American Indians have the highest smoking rate  of any racial group in Minnesota, with 59% of adults smoking compared to 14% of the entire adult population. Read more from the Star Tribune and learn more about sacred tobacco from Clearway