The dental danger of water pipe smoking

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water pipeCigarette smoking is on the decline, but water pipe smoking is more popular than ever-with users often unaware of the dangers, writes Meg Crawford.

A doctor somewhere hot, sandy and exotic once fashioned a water pipe (also known as a hookah, shisheh and argileh) for his aristocrat boss. His invention was based on the premise that the water would purify the smoke and, therefore, create a less harmful way to inhale tobacco smoke. Of course, he was quite wrong.

That said, it’s not the only time that doctors have encouraged tobacco smoking. Take, for example, a vintage anachronism-the 1940’s ads in which surgeons regaled the public with the virtues of cigarettes. However, in the decades since, attitudes towards cigarettes have changed radically. Doctors now actively dissuade patients from smoking, advertising is banned, cigarette smokers are social pariahs and the incidence of cigarette smoking has dramatically waned. In stark contrast, the incidence of hookah smoking has not only increased, people still labour under the misconception that it’s a safer way to inhale-suffice to say, it’s not.

What is a water pipe?

Traditionally, a water pipe is made up of a head, body, tube with a mouthpiece and water bowl. The tobacco, which goes in the head of the pipe, isn’t directly lit-usually, the tobacco is covered and coals are placed on top. The charcoal vaporises the tobacco and the user inhales through the mouthpiece and pipe, drawing smoke from the head, through the body of the waterpipe and the water in the bowl. The process of drawing the smoke through water and across a variety of surface areas in the process cools the smoke, which may have given rise to the belief that it was a less harmful method of smoking.

Water pipes are now smoked all over the world-but their use has been extensively documented for over four centuries in Africa and Asia. The custom is also prevalent in Australia, where shisha bars are not uncommon, people smoke hookahs at home and, culturally, it’s regarded as fun and safe.

“A water pipe smoker may inhale as much smoke during one session as a cigarette smoker would inhale consuming 100 or more cigarettes,”-World Health Organisation study on water pipe smoking

Dr Catherine Groenlund, a private dental practitioner at Taylor, Gronlund and Doan family dental practice, and former lecturer and associate dean at Sydney University’s Faculty of Dentistry, is aware of the prevalence of the practice and myths surrounding water pipe smoking. “I had a patient, who was about 45 [years old], come in with her child,” Dr Groenlund says. “She said she didn’t smoke anymore and had given it up because she knew it was bad, but uses a hookah at home-she goes home and has a couple of hours on the hookah as a way to relax.”

Dr Groenlund’s also had teenagers admit to the practice, albeit after a bit of probing. “Recently, I had a 17 and 19-year-old come in, who both said they smoked only around 10 cigarettes each day,” Dr Groenlund says. “Then I asked them if they smoked something else. Both boys said they smoke hookahs two or three times each week.

“It seems to be popular with young guys and women. The women often have their own hookah at home and then, if they have a big party, everybody has a go. From what I can see, it’s a cultural thing and something you can do with other people and enjoy it. Cigarettes are now socially unacceptable, but this is socially fine.”

What’s smoked in a water pipe?

Most commonly, “maasel” is smoked in waterpipes-a type of tobacco fermented in molasses and flavoured with fruit and other essences. Evidence indicates that flavouring tobacco products also makes it more appealing to a younger audience. “It tastes better with flavours in it,” Dr Groenlund says. “I’ve been told the flavour of the month is apple.”

Where can you smoke a water pipe?

It’s lawful to smoke a water pipe on private property and most places outdoors (although not anywhere subject to normal smoking bans, such as train stations). In contrast, smoking a water pipe in a workplace (which includes a restaurant or bar) anywhere in the country (other than in Victoria) is banned.

Although lobbyists are working hard to change this, the Tobacco Act 1987 (Vic) prohibits smoking tobacco products in workplaces only if the main ingredient is tobacco. Because tobacco is not necessarily the main ingredient in maasel it often slips under the radar. Elsewhere in Australia, definitions of tobacco products are expanded to include anything which contains tobacco.

What dangers are associated with smoking a hookah?

Alarmingly, the time for which people sit smoking water pipes almost always vastly exceeds the time it takes to smoke a cigarette, and greater volumes of smoke are inhaled. In fact, the World Health Organisation’s study note on water pipe tobacco smoking states that “a water pipe smoker may inhale as much smoke during one session as a cigarette smoker would inhale consuming 100 or more cigarettes”.

Naturally, all of the dangers related to cigarette smoking, such as lung cancer and disease, low birth weight, respiratory illnesses, chronic obstructive pulmonary disease and nicotine addiction, apply to water pipe smoking, plus a few extras-in particular, periodontal disease. “The boys who told me they smoked hookahs had gingival inflammation, and they’re only young,” Dr Groenlund says. “The lady had chronic periodontitis. Most people who smoke are going to have some sort of periodontal disease, but the dental challenge from smoking a hookah is much greater than smoking a cigarette.”

Waterpipe use also carries the risk of contracting communicable diseases, such as oral herpes, hepatitis and influenza, which stem from sharing mouthpieces.

How does dental practice need to change?

Dr Groenlund has some clear ideas about how the issue should be tackled with patients. “Ask your patients whether they are smoking hookahs first of all,” she says. “Then you have to warn them about the risks, specifically the periodontal risks. If someone is doing it-measure their periodontal status and check it regularly to see if the status has changed. At the moment the biggest problem is that it’s regarded as good to do and, culturally, it’s fun. So, I’m going to talk to our community outside of the surgery-for example talking to a mothers group. Somehow, the practice needs to be made less socially acceptable.”

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