Challenging Dogma - Fall 2009

Wednesday, December 16, 2009

Harmful Hookah- Sofia Aba Jebel


Manifested in latent trends, international health patterns are exposing the consequential residue of globalization and technology; infectious, communicable, chronic and acute diseases alike are no longer outlined by a particular nation’s geographical boundaries. Single, double or triple burdens of disease are not mutually exclusive to either the Global North or South. Whether caused by HIV/AIDS (+TB) or tobacco related cancer, the world’s leadings causes of morbidity and mortality are universally determined by knowledge-sharing practices, economic climate and kinetic socio-cultural values.

The long-standing smoking cessation battle between Multi-National Tobacco Corporations and US Anti-Smoking lobbyists/campaigns is globally recognized as part of the US’ Public Health repertoire. Public Health Institutions such as the CDC, World Health Organization and like institutions have conducted global studies on the impact of tobacco usage on health outcomes. In Egypt approximately one-quarter of the population (16 million) are tobacco users. (1) With over 50% of the adult male population consuming tobacco, smoking related morbidity and mortality rates are on the rise. (1) As a result the government has suffered economically in order to fund the corresponding health care subsidies. The direct annual cost of treating disease cause by tobacco use in Egypt is estimated at 3 billion Egyptian pounds. (9)

The Egyptian government launched a two-part national campaign to reduce tobacco usage. The initial objective of the campaign was to reduce the desire to smoke: imposing immoral values on tobacco usage. In 2003, Health Ministry officials partnered with Muslim leaders to officiate a “fatwa” or Islamic ruling against tobacco usage. (2) The Health Ministry has also required cigarette companies to publish images of the “harmful effects of smoking” on cigarette packaging. (1) Since then, increased rates of tobacco usage have persuaded Government officials to shift their attention from efforts to reduce the desire to smoke towards efforts to reduce the access to smoke. Similar to the US’ smoking-cessation movement, the campaign is supported by legislation which prohibits smoking in public spaces such as restaurants, cafes, etc. The Health Ministry’s smoking-cessation initiative is confronted with challenges that are culturally specific to traditions of the Middle East. Tobacco users in Egypt are identified as both cigarette and Hookah smokers.

As ineffectual as most cigarette cessation programs may be, successful interventions piloted by other countries offer precedence in shaping models of efficacious cigarette-specific smoking cessation campaigns. The Egyptian tobacco campaign applies their intervention against cigarette usage to hookah practices. In their efforts to tackle tobacco as one issue, the Egyptian Health Ministry is treating two historically, politically, economically and culturally different vectors for tobacco-related morbidity as one.

Typically, a tourist’s urban adventures through Cairo include the commodified experience of smoking hookah at a local café. The tourism industry contributes as a major source of foreign currency as well as 4% of Egypt’s annual GDP.(8) Although legislation presented significant financial risk, after a cost-benefit analysis, in November 2009 the government re-launched their policy, prohibiting cafes and restaurants from smoking publically. (1) Immediately, historical and cultural landmarks such as the Khan el-Khalili bazaar became more vacant and less trafficked. (1) Though the policy was designed to protect the health of customers, store owners and tourists, business owners protested immediately in order to protect their livelihoods. The policy was quickly overturned in response to the protests. In a seemingly unrelated exchange, store owners promised to improve the hygiene of their shops.

Traditional Education Efforts

Cigarette cessation programs illustrate the inefficiencies of health education campaigns designed to change health behavior. The Egyptian Health Ministry’s smoking cessation campaign is centered on health education outreach initiatives. This campaign is founded on traditional public health models such as the Health Belief Model. The model assumes that an individual’s intention directs their behavior. According to the Health Belief model, the individual makes a decision after measuring the perceived benefits against the perceived barriers. (10) The problem with this model, as observed in tobacco-related initiatives, is that the model does not acknowledge the complexity of the individual psychology to weigh irrational and rational variables. (11) (12)

Successive theories such as the Theory of Reason to Action and the Theory of Planned Behavior further emphasize an individual’s ability to effectively make a decision after calculating the perceived benefits, barriers, and perceptions of others. Though there is great potential for an individual to undergo these rational processes, it is unlikely. These theories do not recognize spontaneous behavior or the context under which activities are presented/marketed. (12)

The campaign informs hookah users (and in particular tourists) of the imminent threat of sharing water pipes: potentially contracting swine flu. According to traditional public health theories, the tourist will be expected to make a rational decision between the outcomes. However, in reality a tourist in Egypt in better described as adventure-seeking, willing to enjoy the short-lived thrill of experiencing activities in a foreign city. The thrill of smoking hookah for one hour in an exotic city in Egypt is not contaminated with messages of the activity’s associated risk.

Sources of Implicit Racism

The challenge for public health officials is the popularly shared belief that smoking hookah is less harmful than smoking cigarettes. To challenge these beliefs health officials are using studies to support messages of the harmful effects of hookah. The studies used to collect findings have been conducted by WHO, CDC and like ‘western’ institutions, not by Egyptian health authorities therefore the lay population does not trust the sources. (1,7) World Health Organization’s Dr. Fatima El-Awa describes smoking hookah as the “equivalent of smoking 100-200 cigarettes.”(6) The tobacco composition used in hookah is not standardized; therefore it’s difficult to generalize its effects. Although of the studies conducted, evidence of high carbon monoxide, nicotine, “tar” and heavy metal concentration are found in the aerosol. (13)

These concentrations were as high if not higher than cigarettes and in several studies have shown that smoking hookah has double the effects of smoking cigarettes. (1) (14)

Convictions of implicit (and potentially explicit) institutionalized prejudice against Egyptians and cultures of the Middle East have been organized into (conspiracy) theories. One response to the public health messages supported by WHO and the US’ CDC is led by the Narghile group. The Narghile group explains that large, imperial, Eurocentric institutions are determined to eliminate traditions at the core of Arab culture and society. (7) Narghile has reframed smoking hookah as a youth-centric resistance movement charged to protest the oppression of cultural and religious traditions. The Psychological Reactions theory explains this process as a reverse psychology. The reaction to these campaigns are emotional reactions in response to the threat of a specific freedom; smoking hookah. Unfortunately, the theory explains that in reaction to the public health message the targeted population may adopt or strengthen the very message that is contrary to what was originally intended by the message, and in some instances resist interventions to persuasions. (15)In response to the evidence-based public health education initiatives, smoking hookah has been reframed as an act of resistance and to preserve the integrity of Egyptian national identity. (7)

Reframing Random Risk

In order to supplement methods used to reduce public smoking, the Health Ministry has borrowed an approach from Kuwait in order to reduce the desire to smoke Hookah. (1) Health officials used the momentum of the Swine Flu hysteria to reframe smoking hookah as a potential vector for spreading the virus. Smoking hookah is typically a group activity where participants use the same water pipe to ingest the smoke. North of Cairo, in Aswan, the Governor banned smoking hookahs in cafes to protect tourists and locals. (3) Tourists’ response to this message has not yet been measured. Locals however, have resisted this notion under the premise that the chances of them contracting swine flu from using hookah are unlikely.

In the past three years, of the 83 flu cases in Egypt only 27 have resulted in death. (3) On average, outside of Asia this is the most densely reported case of flu death. (3) In 2009, Egypt reported 943 cases of swine flu. (3) Although the incidence is high (1.1%), the lay population’s perceived susceptibility is low. The theory of small numbers lends an explanation to this phenomenon. The theory of small numbers explains that people do not have an accurate conceptual and mathematical understanding of what it means for an occurrence to be random. (16) People overestimate the probability that numbers, diseases, etc will not repeat. Though statistically, one’s chances may remain high for contracting Swine Flu by sharing a water pipe, an individual’s perceived risk is low because of an underestimated calculation of susceptibility. A local customer, Ali Safa reports “it will never stop the spread of the deadly swine flu virus since it’s just (at the very small guess) one of the [transmission] sources.” (5) Though Safa acknowledges swine flu as a “deadly virus” he also understands smoking hookah as only one of the innumerable ways to contract the virus. Therefore, the likelihood that one would contract the virus from smoking hookah is not high enough for him to recognize the behavior as risky. (5)

Instead of changing attitudes towards the threat of hookah, reframing hookah in the context of swine flu has made local hookah users more apathetic towards swine flu prevention techniques. This unanticipated response is best described by another local Hookah user “they’re sending the wrong message to the public, admitting that they can’t do anything and instead stop trivial things like shisha or our tradition of kissing friends on the cheeks.” (5) An unintended consequence of this campaign has diluted the importance of swine flu prevention techniques. (5)

B. Proposed Intervention


According to the World Bank, Egypt accounted for 24% of total tobacco usage in the Middle East North Africa region. (13) In 1999, Egyptians consumed a total of 46,000 cigarettes which contributes significantly to the tobacco market. (13) Ten years later the WHO reported that almost a third (29.9%) of the adult population (18+) uses tobacco in Egypt. (9)WHO findings suggest that higher consumption rates exist among men: 59.4% and 2/3 of this population are daily smokers in contrast to the 2.7% of adult females. (9) Users between the ages of 13 and 15yrs who use tobacco products other than cigarettes account for 10% of the youth population with a higher prevalence amongst boys 12.3% to 6.7% females. (9) The interventions targeted population will be the young adult male since they are the most prevalent of users.

Since tobacco usage is embedded in Egypt’s social, cultural and economic structure and affects more than a quarter of the total population, effective interventions will have to approach the issue in stages. The following interventions will fall under a theme of a “harm reductionist” approach. The Harm reductionist approach is a new concept to manage campaigns designed to ultimately eliminate tobacco consumption. Prohibiting hookah in Egypt to lower tobacco related morbidity is as successful technique as promoting abstinence to prevent HIV/AIDS. It will take time before any campaign is successful enough to observe results; people are going to keep smoking and until they stop it will not be sufficient enough measure to prohibit the act.(17)

Social Marketing

Current campaigns fail to address the social and cultural significance of smoking hookah. In Egypt and the Middle East, Hookah is perceived as a cultural icon. Hookah was only introduced to Egypt by the Ottoman Empire 200 years ago. Given the spectrum of Egypt’s rich history, hookah is, arguably, only a cultural icon of Egypt’s modern history. (18) Cigarette companies have been successful, in part because they have marketed cigarettes to a global demographic; penetrating the wealthy, the impoverished, the young and old alike. The tobacco plant may have originated in China, but cigarettes are not perceived as a Chinese product. Hookah, however, has been regarded as a product of the Middle East. Theories on irrational behavior explain that people are less likely to give up habits if the habit provides the individual or community with a sense of ownership. Two strategies to challenge tobacco ownership ideals are to first market the product as not indigenous to Egyptian culture and to substitute tobacco product with tobacco- like products.

The likelihood that Egyptians will give up ownership of a tradition in exchange for preserving their health (defined by western institutions) is low. In order for Egyptians to give up hookah they would have to be willing to release ownership of hookah to gain ownership of something larger than a socially unifying tradition perceived as unique to their culture. Hookah at the individual level also provides immediate and inexpensive satisfaction. Campaigns should aim to redefine hookah as a non-indigenous product.

Campaigns will promise a restoration of Egyptian culture, illustrated by a “new movement” to preserve true tradition. Government sponsored campaigns can market “hookah” as a product encouraged by tourism industries that have projected an exotic ideology on the Egyptian experience. Images of modern cafes in the 1800s displayed alongside images of today’s modern cafe will illustrate a comparison of true tradition vs. an unattractive modernization of a cultural pastime: drinking coffee/tea at a cafe. The new campaign would encourage Egyptians to restore their culture back to its indigenous roots. Café and restaurant owners will be more inclined to observe the smoking ban if they are subsidized by the government. At the expense of a marketing campaign, and small business owner subsidies the government would gain financially by preserving the (health of the) tourism industry as well as reducing long term health care costs.

According to Ogilvy and other leading marketing pioneers a successful campaign must demonstrate a worthy promise as well as support. (19)The health ministry should partner with advertising firms to produce billboards, commercial advertisements and tourism advertisements to promote the revitalization of Egypt. The campaigns will be youth friendly and will support their mission to preserve the integrity of Egyptian culture. What did Egyptians do before the Ottoman Empire? Images posted would replace hookah with traditional board games such as backgammon, etc. Although board games are currently being playing in conjunction with hookah, these images would reintroduce images of active, positive, hand-held traditional activities.


In tobacco related campaigns, according to tobacco researchers Kathleen Stratton and Padma Shetty, et al, a harm reduction product is a product which “lowers total tobacco related mortality and morbidity even though use of that product may involve continued exposure to tobacco related toxicants.” (17) There are several ways to implement policy in order to reduce the overall harm of a product. A harm reductionist approach acknowledges that it will take time to reshape the image of a (tobacco related) two hundred year old tradition. In the interim, café owners should be required to replace tobacco with tobacco like products, or tobacco with lower concentrations of nicotine. Currently, there are emerging products such as New Smoking Material (NSM)”, and electronic cigarette vapors. Though several studies have indicated that tobacco products that contain as little as %30 “New Smoking Material” will reduce harmful effects. (23) The Egyptian Health ministry should conduct studies to test these products and if the findings are positive should initiate an intervention requiring café owners to supplement their tobacco products with substitute products.

Substitute material will allow the hookah smoker to continue “owning” the tradition or product. A local electrician explains that without a substitute the policy will rob people of their stress relieve mechanisms. Maslow’s hierarchy of needs describes that if basic needs aren’t met, the lay, non-public health community will not prioritize other needs.(20) Saad Eddin Muhammad explains “this is just going to give some people more authority now to go after those poor citizens who take out their daily worries with the smoke they blow out of their mouth.”


Individual behavior must be supported at a systems level. Brofenbrenner describes this by drafting an individual’s ecological chart. (21) At the outermost layer policy should work its way towards the center of the diagram such that once the individual stops smoking hookah, that particular habit is supported by the infrastructure of their family, community and society at large. The government should therefore reinstate its policy to prohibit public smoking in cafes, restaurants, etc. In order to help support the campaign the government should list icons in pop culture to help convert the image of smoking hookah: Changing the social norm by targeting early adopters. Social Network theory also explains that once a cluster of non-smokers builds the cluster tends to grow and spread. According to the Social Expectations theory once the policy is implemented, overtime, not smoking hookah will develop into a social norm. Legislation alone may inspire a black market or low compliance so to reinforce policy trend setters will be implemented. (22)


Since tobacco usage is such a prevalent issue in Egypt, smoking-cessation campaigns will have to be designed in layers. A specific challenge that the Egyptian Health Ministry must acknowledge will be combating the centuries old tradition of smoking hookah. Effective campaigns must approach the issue from several vantages points: the individual, social, cultural, political, national level and global level. The pleasures of smoking hookah will not go away with one billboard nor unenforced legislation. The campaign must be comprehensive in and diligent in the health ministry’s efforts to replace one bad habit to restore a nation’s health.


1) “Egypt Attempts Crackdown on Shisha” Al Jazeera. 4 December

2) Radwan GN, et al. “Impact of Religious Rulings (Fatwa) on smoking” Journal of the Egyptian Society of Parasitology 2003. 33; 1087 101


4) Tversky A, Kahneman D. Belief in the law of small numbers. Psychological Bulletin 1971; 76:105-110

5)Garcia B. “Shisha ban unwelcome but beneficial, say doctors, MP” Kuwait Times. 2009.

6) Mojon J-M “’Hamless Hookah’ targeted in Egypt health drive” Daily News Egypt. 2006

7) Narghile Group Company. “7 Fatal Errors of in the WHO “Waterpipe” Flawed Expert Report” 2009

8) Egypt Country Profile: Oxford Business Group. <>


10) Rosenstock IM. Historical origins of the health belief model. Health Education Monographs 1974; 2:328-335.

11) DeMartino B, Kumaran D, Seymour B, Dolan RJ. Frames, biases, and rational decision-making in the human brain. Science 2006; 313:684-687

12) Individual health behavior theories (chapter 4). In: Edberg M. Essentials of Health Behavior: Social and Behavioral Theory in Public Health. Sudbury, MA: Jones and Bartlett Publishers, 2007, pp. 35-49.

13) Source: World Health Organization. (1998). World Health Statistics Annual, 1996.Geneva, Switzerland

14) Knishkowy B, et al. “Water-Pipe (Narghile) Smoking: An Emerging Health Risk Behavior” Journal of American Pediactrics. 2005. 116: 113-119

15) Silvia PJ. Deflecting reactance: The role of similarity in increasing compliance and reducing resistance. Basic and Applied Social Psychology 2005; 27:277-284.

16) Tversky A, Kahneman D. Belief in the law of small numbers. Psychological Bulletin 1971; 76:105-110.#4

17) Stratton K, et al. “Clearing the smoke: the science base for tobacco harm reduction – executive summary.”Tobacco Control. 2001. 10:189-195!

18) Slackman M. “Antismoking Fight Proves a Pyramid-Size Task” New York Times. Cairo Journal: 2009.

19) Ogilvy D “How to build great campaigns”Confessions of an Advertising Man. New York: Atheneum, 1964, pp. 89-103.

20) . Maslow AH. A theory of human motivation. Psychological Review 1943; 50:376


21) Brofenbrenner, U. (1994) Ecological modesl of human development. In INternatioanl Encyclopedia of Education, Vol. 3, 2nd. Ed. Oxford: Elsevier. Reprinted in: Guavain, M. & Cole, M. (Eds.), Readings on the development of children, 2nd Ed. (1993, pp. 37-43). NY: Freeman

22) Sornette D “’Herd behavior and “crowd” effect and Forces of imitation”. Why Stock Markets Crash: Critical Events in Complex Financial Systems. Princeton, NJ: Princeton University Press, 2003, pp. 91-114.

23) Warner K. “Tobacco harm reduction: Promise and perils” Oxford Journals: Nicotine & Tobacco Research. 2002. 4; s61-s71



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