This paper aims to provide a background to the phenomenon of waterpipe smoking during the present COVID-19 syndemic. In the context of a syndemic, it seeks to summarise what research findings have revealed to date of the specific dangers of this form of tobacco use in the current situation, in terms of the particular dangers of the use of the apparatus itself, social settings in which waterpipes are smoked, and the perceptions of smokers themselves on the potential harms at this time. A narrative review, based on a focused search of electronic databases, was conducted, which resulted in a final list of 49 articles which were selected for inclusion in the paper. The results obtained from this review provided strong confirmatory evidence of the specific dangers both of transmitting infection via the waterpipe apparatus, whatever its regional variation, and the social milieu in which transmission of the COVID-19 virus was likely to be increased. The discussion of the results of the research was then widened to include what is known about the beliefs of smokers in general, and waterpipe smokers in particular, on the health risks of waterpipe smoking and the likely transmission and severity of the COVID-19 virus. Introduction: A number of published studies have investigated diverse aspects of the impact of COVID-19 on various aspects of the behaviour of individuals during lockdowns. These include a survey conducted in Italy into eating habits and lifestyle changes (Di Renzo et al, 2020), sedentary time and behaviour (Runacres et al, 2021). cannabis use in Spain (Fernandez-Artamendi et al, 2021) and smoking. It is those studies relevant to waterpipe (hookah) smoking behaviour during the present COVID-19 syndemic which form the basis of the discussion in this paper. First, however, the choice of the term syndemic rather than pandemic should be explained (Horton, 2020; Medenhall, 2020; Courtin and Vineis, 2021). What drives the coronavirus to spread through the population of a specific region or country is an interaction of particular political, social, economic and cultural factors. Patterns of social inequality exacerbate the adverse effects of the disease. Recognising these determinants of health is central to the concept of a syndemic., rather than the narrower perception of the COVID-19 outbreak as a biomedical issue. Synergistic failures cannot be omitted from the discussion of forms of tobacco use or a wide range of causes of ill-health, including viral diseases, and how to combat them in the future. For example, Gaiha and colleagues (2020) conducted an online national survey of over 4000 adolescents and young adults (aged 13-24) in the USA in May 2020, investigating a possible association between cigarette and e-cigarette use and COVID-19. One finding This paper aims to provide a background to the phenomenon of waterpipe smoking during the present COVID-19 syndemic. In the context of a syndemic, it seeks to summarise what research findings have revealed to date of the specific dangers of this form of tobacco use in the current situation, in terms of the particular dangers of the use of the apparatus itself, social settings in which waterpipes are smoked, and the perceptions of smokers themselves on the potential harms at this time. A narrative review, based on a focused search of electronic databases, was conducted, which resulted in a final list of 49 articles which were selected for inclusion in the paper. The results obtained from this review provided strong confirmatory evidence of the specific dangers both of transmitting infection via the waterpipe apparatus, whatever its regional variation, and the social milieu in which transmission of the COVID-19 virus was likely to be increased. The discussion of the results of the research was then widened to include what is known about the beliefs of smokers in general, and waterpipe smokers in particular, on the health risks of waterpipe smoking and the likely transmission and severity of the COVID-19 virus. Introduction: A number of published studies have investigated diverse aspects of the impact of COVID-19 on various aspects of the behaviour of individuals during lockdowns. These include a survey conducted in Italy into eating habits and lifestyle changes (Di Renzo et al, 2020), sedentary time and behaviour (Runacres et al, 2021). cannabis use in Spain (Fernandez-Artamendi et al, 2021) and smoking. It is those studies relevant to waterpipe (hookah) smoking behaviour during the present COVID-19 syndemic which form the basis of the discussion in this paper. First, however, the choice of the term syndemic rather than pandemic should be explained (Horton, 2020; Medenhall, 2020; Courtin and Vineis, 2021). What drives the coronavirus to spread through the population of a specific region or country is an interaction of particular political, social, economic and cultural factors. Patterns of social inequality exacerbate the adverse effects of the disease. Recognising these determinants of health is central to the concept of a syndemic., rather than the narrower perception of the COVID-19 outbreak as a biomedical issue. Synergistic failures cannot be omitted from the discussion of forms of tobacco use or a wide range of causes of ill-health, including viral diseases, and how to combat them in the future. For example, Gaiha and colleagues (2020) conducted an online national survey of over 4000 adolescents and young adults (aged 13-24) in the USA in May 2020, investigating a possible association between cigarette and e-cigarette use and COVID-19. One finding Firstly, the smoking of waterpipes in cafes presupposes communal use – the sharing of a single mouthpiece and hose, and the impossibility of physical distancing in this social environment. Secondly, in waterpipe cafes Alagaili and colleagues (2019) noted the lack of routine cleaning of the waterpipes after each smoking session, further increasing the risk of transmission of infectious microbial agents. In addition, these cafes throughout the world tend to be densely occupied and badly ventilated (Kalan et al, 2020). Daniels and Roman (2013) note that sharing a waterpipe contributes to a range of tuberculosis, viral and bacterial infections when an infected user shares a mouthpiece with non-infected individuals through the transmission of oral secretions. The contention of Daniels and Roman, of course, precedes the COVID-19 syndemic. Corroborative evidence is provided, in the context of COVID-19, in a study by Sinclair and colleagues (2021). This was a convenience sampling study conducted in the Lao People’s Democratic Republic in July 2011 where, although the waterpipe has a simple bamboo construction, the parts still perform the same function as the Eastern Mediterranean waterpipe. In this study, samples were taken from the water bowl of the waterpipe, and the field assessment of water quality indicators showed that the water inside the Lao waterpipes had the potential to be contaminated by various types of micro-organisms. In addition to microbial mechanisms, infectious disease exposure – such as to the COVID-19 virus – was identified as a potential risk. The virus thrives in dark, humid environments and will be spread through communal use in the smoking process. In Turkey, Altindis and colleagues (2020) analysed culture samples from 182 waterpipes used in public places. The inside and outside of the mouthpiece were sampled, along with water from the waterpipe bowl. The mouthpiece – inside and outside – and the handle were found to be the most affected parts in terms of bacterial contamination. The role played by hand contact is evident in the results found from analysis both of the handle and the outside of the mouthpiece. The significance of the findings – that microbiological growth in the waterpipe samples collected from the public establishments was very high – is that they indicate that waterpipe smoking increases the likelihood of the transmission of respiratory pathogens, including viruses as well as tuberculosis (Sinclair et al, 2021), fungi and a range of other bacteria. The study did not analyse samples from the interior of the hoses, although the authors cite other earlier research which tends to confirm their findings (Safizadeh el al, 2014; Alaidarous et al, 2017; Shakhatreh et al, 2018). Although the majority of these studies, therefore, pre-date the outbreak of the COVID-19 syndemic, they clearly underpin the concerns expressed by Shekhar and Hannah-Shmouni and the WHO about the potential risks of waterpipe smoking for increased transmission of the virus. A summary is provided in Table 1 below. Discussion: Evidence for the many harms resulting from cigarette smoking has been furnished by innumerable studies, to the effect that the best efforts of the tobacco industry have been unable to contest the findings, which are now universally acknowledged. In terms of cigarette smoking and health risk beliefs during the COVID-19 syndemic, Brown (2021) has published a useful review of the findings to date. As he indicates, some studies have concluded that current or former cigarette smokers are at higher risk of contracting more severe symptoms of COVID-19, or even mortality, than never-smokers. The proponents of the opposing case argue that nicotine may have a protective role in those who contract COVID-19 (Simons et al, 2021, Lippi and Henry, 2020: Rossato et al, 2020). Several articles have considered the evidence for both claims, including Cattaruzza et al (2020), Samet (2020) and Shastri et al (2021). The survey results obtained by Brown (2021) indicate that – in the UK, at least - that the perceived probability of contracting COVID-19 correlated with motivation to quit cigarette smoking. Having reviewed the findings of studies on the dangers of cigareete smoking in relation to COVID-19, it remains to discuss the perceptions of waterpipe smokers on the risks posed by the syndemic. As in the case of cigarette smoking, the evidence for the harms occasioned by waterpipe smoking is overwhelming. These harms include significant association with lung cancer, respiratory illness, bladder and oral cancers, and heart disease among its many serious risks (Akl et al, 2011; El-Zaatari et al, 2015; Waziry et al, 2017). A full and recent appraisal of these harms may be found in Darawshy et al (2021). The waterpipe smoke – a mixture of tobacco and molasses known as ‘maasel’ - is cooled as it passes through the base of the waterpipe, enabling smokers to inhale it deeper into their lungs. However, despite such evidence, waterpipe smoking is widely considered to be less harmful than cigarette smoking (Jaam et al, 2016). There is a misconception that passing smoke through the water acts as a cleaning process to remove toxins (El-Zaatari et al, 2015) along with the view that the intermittent practice of waterpipe smoking is less harmful compared with the constant use of cigarettes (Qasim et al, 2019; Maziak, 2008). A single waterpipe smoking session typically lasts for 30-90 minutes, during which time a large volume of smoke is produced. This contains the equivalent of 80 times more toxicants than those found in the smoke of a single cigarette (Al Ali et al, 2020). The effect on smokers, and second-hand smokers, in cafes, homes or meeting places has serious health implications. The tobacco industry has played a role in promoting this confusion (Ahmad & Dutra, 2019; Maziak, 2008). In fact, waterpipe users are exposed to many of the same toxic compounds as cigarette users, although at levels which are much higher (Qasim et al, 2019; Rezk-Hanna & Benowitz, 2019) While there are estimates of 100 million waterpipe smokers globally (Al Ali et al, 2020; Ward et al, 2005), these are less useful than national and regional studies in identifying trends. The WHO Tobacco Atlas (2015) adopts such a national approach to the prevalence of waterpipe use, for example to identify trends in Syria, 1955-2000. Jawad et al (2018) adopt the same approach for the Middle East and Europe. Maziak (2008) summarises the principal trends. Although prevalence is highest in the Middle East and North Africa, waterpipe use is growing rapidly in Europe and the Americas (Babaie et al, 2021; Akl et al, 2011). The practice declined during most of the 20th century, but waterpipe smoking saw a rapid increase in popularity in the 1990s coinciding with the introduction of sweetened waterpipe tobacco (‘maasel’). The tobacco industry commercialised and glamourised the practice on the internet and mass media, especially targeting the youth market. Studies of waterpipe smoking indicate increases since that time in most countries both for daily use and ever-use, with the greatest increases among the youth, both boys and girls (Maziak et al, 2014). A growing number of national studies confirm this trend and Jawad et al (2016) provide confirmatory evidence from the Global Youth Tobacco Surveys. In their systematic review, Babaie et al (2021) draw attention to the management and prevention of waterpipe tobacco use, noting that waterpipe products are still tax exempt, but although taxation has been effective in controlling cigarette smoking, this may not be the case with waterpipe use (Jaam et al, 2016; Maziak et al, 2014). In the present situation of the presence of COVID-19, the association of waterpipe smoking with the restaurant and cafe culture – an influential factor in its growth and popularity – has induced some authorities to institute bans on these places. The Eastern Mediterranean Regional Office (EMRO) of the WHO has reminded its 19 member states that, as signatories to the Framework Convention on Tobacco Control, they have a legal obligation to ban smoking in all indoor public places. 17 of the member countries have banned waterpipe use temporarily in public places (WHO, 2022 (i)), though full implementation of the legislation is necessary to put this into effect. The WHO EMRO has publicised the measures taken in Iran to ban waterpipe use in public places to limit the spread of COVID-19 (WHO, 2022 (ii)) as an instance of what can be achieved through determined policy implementation. The Eastern Mediterranean Region still has the highest prevalence of waterpipe smoking in the world (Shihadeh et al, 2004). Two recent studies from this region investigated the relationship between beliefs and tobacco use behaviours and the risk of COVID-19 infection among samples of smokers and never-smokers. Both studies included waterpipe smoking in their surveys. Firstly, in Iran, Kalan and colleagues (2020) included 89 waterpipe smokers among respondents in their online national survey. From the responses, 38.2% of waterpipe smokers considered that waterpipe smoking was related with spreading infection of COVID-19, compared with 14.6% of cigarette smokers who believed that cigarette smoking was related with spreading infection of COVID-19. Of all the 944 study participants as a whole, 29.1% thought that cigarette smoking was related with spreading COVID-19 infection, compared with 49.4% who believed that waterpipe smoking and spreading COVID-19 were related. The survey also found that waterpipe smokers (approximately 1 in 4) were more likely than cigarette smokers and never-smokers to believe that smoking waterpipe at home was safe during the syndemic, and that smoking waterpipe would have a protective effect and lead to more rapid recovery if they were to be infected with COVID-19. This is all the more concerning, since in Iran waterpipe-home delivery services have become popular with the closure of cafes due to government bans (Kalan et al, 2021). Such perceptions of the safety of waterpipe smoking will increase risk for the smokers themselves and those – such as the family in the home – with whom they interact. A second study into health beliefs and tobacco use during the syndemic also included waterpipe smokers among the participants. In Jordan, an online survey conducted in March 2021 by Al-Tammemi and colleagues (2021) included 2424 participants. Among the findings related to waterpipe smoking, respondents recorded their opinions on the relationship between smoking and domains of COVID-19 such as risk and spread of infection, safety concerns of smoking in public places and the home, clinical outcome and the belief in the protective effective of nicotine. Approximately 38.2%, 72.9% and 44.6% of respondents believed that cigarette smoking, waterpipe smoking and e-cigarette smoking respectively were related to the risk of contracting COVID-19. Clearly, participants considered that waterpipe smoking constituted a much higher risk. About 74% also considered that severity of COVID-19 would be worse for waterpipe smokers, ans almost 80% believed that waterpipe smoking in public places was unsafe during the syndemic. Conclusion: All the evidence suggests that waterpipe smoking poses its own unique set of risks and hazards during the COVID-19 syndemic. When combined with the well-established dangers of tobacco use in causing mortality and morbidity, contributing to a wide range of illnesses, the particular features of waterpipe smoking – the social setting, the apparatus used, the perceptions of waterpipe smokers themselves – all present a cause for concern. This review has concentrated on the research conducted in the Middle East region, both before and during the COVID-19 syndemic. While this region constitutes the highest use of waterpipe smoking, it is necessary to emphasise again that current research has alerted health authorities on the growing widespread use of waterpipes as a global problem, along with e-cigarettes and even e-hookah innovative products promoted by the tobacco industry. Misinformation disseminated by the industry has aided in influencing perceptions and endangering lives. More information is now required on motivation specifically to quit waterpipe smoking since the start of the syndemic, along with an appraisal of the effect of bans on waterpipe cafes in those countries where such bans have been applied.
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