by: Zahra Bashir - Community Health Worker
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:
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.