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Midwakh/Dokha Tobacco Use in the Middle East

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Midwakh/Dokha Tobacco Use in the Middle East TC Online First, published on October 23, 2014 as 10.1136/tobaccocontrol-2013-051530 Special communication Tob Control: first published as 10.1136/tobaccocontrol-2013-051530 on 23 October 2014. Downloaded from Midwakh/dokha tobacco use in the Middle East: much to learn S Vupputuri,1 C Hajat,2 M Al-Houqani,2 O Osman,2 J Sreedharan,3 R Ali,2,4 A E Crookes,5 S Zhou,6 S E Sherman,7,8 M Weitzman,6 on behalf of the United Arab Emirates Tobacco Control Research Collaborative 1Kaiser Permanente Georgia, ABSTRACT water pipes, used to smoke shisha), bidis (thin, The Center for Health Many alternative tobacco products (ATPs), such as sometimes flavoured, cigarettes wrapped in the Research, Atlanta, Georgia, USA hookahs, have grown in popularity and use beyond their tendu or temburni leaf), kreteks (clove cigarettes), 2United Arab Emirates locale of origin and are therefore becoming a significant pan (betel quid with tobacco) and flavoured cigars University, College of Medicine global public health concern. This article provides an and cigarillos, other ATPs of potential concern and Health Sciences, Institute overview of an under-reported and understudied ATP, have to date largely been unrecognised and thus of Public Health, Al Ain, UAE dokha, which is smoked in a midwakh pipe. It describes have not been studied, monitored or regulated. 3Gulf Medical University, Research Division, Ajman, UAE the state of tobacco control in the Arabian Gulf region This paper examines the use of midwakh/dokha, 4Cancer Epidemiology Unit, where midwakh smoking appears to be most common, an ATP which is widely used in the United Arab University of Oxford, Oxford, the history of midwakh and dokha use, and what is Emirates (UAE) and the Arabian Gulf Region, UK known about midwakh smoking from the published where its use is prevalent and growing in popular- 5Heriot-Watt University, School of Life Sciences, Dubai, UAE literature. On the basis of the stark lack of data on ity. Cursory indications, such as the proliferation of 6Department of Pediatrics and midwakh use, we suggest priority areas to focus future dokha websites and dokha sales at tobacco retailers Environmental Medicine, research. Preliminary data and observations from health internationally, suggest that midwakh/dokha use New York University School of providers and the public health sector suggest that could potentially emerge outside the Gulf region. If Medicine, New York, midwakh smoking may pose challenges to the tobacco true, it may follow a pattern similar to that of other New York, USA 7New York University/Abu control efforts in the Arabian Gulf region. If it is ATPs such as hookahs, which have translated from Dhabi Public Health Research emerging as a new ATP outside this region, there could cultural/traditional use in the Middle East to wide- Center, Abu Dhabi, UAE fi be a signi cant impact on tobacco control strategies spread global increases in use. Similar to hookahs, copyright. 8 Department of Population globally. the marketing of midwakh/dokha is targeted at Health, Medicine and 8–12 Psychiatry, New York University young people. School of Medicine, New York, New York, USA INTRODUCTION Tobacco use in the Arabian Gulf region Correspondence to Tobacco use is pervasive worldwide, and it has In the Middle East and specifically the Arabian Dr Suma Vupputuri, Kaiser profound health consequences for smokers and Gulf region, cigarette smoking has warranted and Permanente Georgia, Center those exposed prenatally or to secondhand or garnered serious public health concern. Among http://tobaccocontrol.bmj.com/ for Health Research /SE, 3495 1 Piedmont Rd, Building 10, third-hand smoke (SHS and THS). Use of tobacco adults in this region, the point prevalence of active Suite 101, Atlanta, GA 30305, remains among the leading contributors to the cigarette smoking was approximately 24% in men USA; [email protected] global burden of disease, accounting for more than and <1% in women, according to one of the 10% of this burden in 2010, and it is the leading largest surveys of adult tobacco use in the UAE.13 Received 17 January 2014 Accepted 27 August 2014 preventable cause of non-infectious disease deaths Further, it has been reported that 82% of students worldwide.12Changes in immigration patterns have tried their first cigarette before the age of have resulted in significant changes in demographic 14.14 While exactly comparable metrics are not characteristics of many parts of the world. This, in available globally, the following provides some turn, has resulted in the introduction and diffusion context from other countries. Among regular cigar- of what had previously been region-specific forms ette smokers in the UK, approximately 65% started 15 of tobacco and tobacco delivery systems to many smoking before the age of 18 years and in the on September 26, 2021 by guest. Protected new parts of the world. USA, the mean age at which youth try their first The increasing use of many such alternative cigarette is 15–16 years.16 The use of tobacco tobacco products (ATPs) in areas that had not pre- among those aged 13–15 years in the UAE is viously encountered them, coupled with the wide- increasing as shown by the Global Youth Tobacco spread implementation of public policies that have Surveys,17 18 which indicates that current smoking proven effective in limiting cigarette uptake and of any tobacco product increased from 18% in facilitating cessation of use, raises great concern 2002 to 20% in 2005. While the use of cigarettes that these ATPs may replace cigarettes as major among those in this age group remained stable at forms of tobacco delivery systems. Evidence of this 7–8%, the use of ATPs such as cigars, pipes, little growing concern is provided by the WHO’s Global cigars, chewing tobacco, snuff and dip increased To cite: Vupputuri S, Youth and Adult Tobacco Surveys, the Canadian from 18% in 2002 to 29% in 2005.17 Hookah use Hajat C, Al-Houqani M, and US National Youth Tobacco Surveys as well as was reported by 11% of participants in both et al. Tob Control Published the addition of many relevant questions to the US years.17 18 These data suggest that the increase in Online First: [please include – Day Month Year] Behavioural Risk Surveillance System Survey.3 7 tobacco smoking prevalence among young adults in doi:10.1136/tobaccocontrol- While substantially increasing attention is being this region may be due in part to the increased use 2013-051530 paid to some ATPs, such as hookahs (also called of other ATPs. Copyright Article author (or theirVupputuri employer) S, et al. Tob Control 2014.2014; Produced0:1–6. doi:10.1136/tobaccocontrol-2013-051530 by BMJ Publishing Group Ltd under licence. 1 Special communication Tob Control: first published as 10.1136/tobaccocontrol-2013-051530 on 23 October 2014. Downloaded from Tobacco control efforts in the Middle East and elsewhere con- is known about the use of other ATPs and alternative tobacco tinue to focus almost exclusively on curbing cigarette use delivery systems emanating from the Middle East to other parts (including smoking cessation training of health and education of the world. The diffusion of the use of these products among professionals, media campaigns, increased taxation and banning the overall population is largely unknown, although almost 20% tobacco smoking in public places), despite the alarming new of US adolescents report having used hookahs and more than research indicating increased use of ATPs. Additionally, there is 2% report having used bidis or kreteks before completing high as yet little evidence on success rates for quit programme school.7 In contrast, virtually nothing is known about the use of methods for ATPs, such as hookahs, which have spread in midwakh in Western countries. This problem is compounded by global use. The limited research literature suggests that many the absence of questions about it on any global or national ATPs may be as harmful as or even more harmful than cigar- tobacco survey outside the Arabian region. Despite this paucity – ettes;19 24 however, with respect to midwakh use, there is a crit- of systematic public health information, numerous North ical lack of data on prevalence, attitudes, knowledge, toxicant American and European websites have emerged that market exposure and health consequences. midwakh smoking, especially to youth, as the ‘the future of tobacco.’827These websites emphasise midwakh smoking as: having ‘more feeling’, time saving, less mess, odourless, eco- What is midwakh and dokha? nomical, the newest trend and as a healthier option than cigar- ‘ ’ Dokha (Arabic for dizzy ) is the tobacco blend that is smoked ettes. The marketing message of midwakh use in the West is that ‘ ’ in a pipe called a midwakh . It is a combination of tobacco of a trendy pastime and it has begun to appear on various mer- fl leaves with a variety of barks, herbs, spices, dried owers or chandise items (figure 2). dried fruit, and is known for its high nicotine content, contain- ing up to five times as much as a normal cigarette.25 26 Dokha use originated in northern Iran in the 15th century8 and wide- The potential emergence of midwakh in the West? spread use among sailors along the Caspian Sea resulted in its The effect of globalisation and population mobility on public 28 introduction into the Middle East in the 1500s. health is not a new concept. With dramatic changes in the The midwakh is used to inhale the smoke of the burning demographics of Europe and North America, we believe that it dokha, and this pipe is structurally different from other Western is possible that the emergence of ATPs, such as hookah use, in smoking pipes (see figure 1).
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