Midwakh/dokha tobacco use in the Middle East: much to larn

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  1. South Vupputuri1,
  2. C Hajattwo,
  3. Thou Al-Houqanitwo,
  4. O Osman2,
  5. J Sreedharan3,
  6. R Alitwo,iv,
  7. A E Crookesv,
  8. S Zhou6,
  9. Southward E Sherman7,8,
  10. M Weitzman6
  11. on behalf of the United Arab Emirates Tobacco Control Enquiry Collaborative
  1. one Kaiser Permanente Georgia, The Centre for Wellness Research, Atlanta, Georgia, USA
  2. ii United Arab Emirates University, College of Medicine and Health Sciences, Institute of Public Health, Al Ain, UAE
  3. 3 Gulf Medical Academy, Research Division, Ajman, UAE
  4. four Cancer Epidemiology Unit, University of Oxford, Oxford, United kingdom
  5. 5 Heriot-Watt Academy, School of Life Sciences, Dubai, UAE
  6. 6 Section of Pediatrics and Environmental Medicine, New York Academy School of Medicine, New York, New York, USA
  7. seven New York University/Abu Dhabi Public Wellness Inquiry Center, Abu Dhabi, UAE
  8. 8 Department of Population Health, Medicine and Psychiatry, New York Academy School of Medicine, New York, New York, Usa
  1. Correspondence to Dr Suma Vupputuri, Kaiser Permanente Georgia, Eye for Health Research /SE, 3495 Piedmont Rd, Building 10, Suite 101, Atlanta, GA 30305, The states; suma133{at}hotmail.com

Abstract

Many alternative tobacco products (ATPs), such as hookahs, have grown in popularity and use beyond their locale of origin and are therefore becoming a significant global public health concern. This article provides an overview of an under-reported and understudied ATP, dokha, which is smoked in a midwakh piping. It describes the state of tobacco control in the Arabian Gulf region where midwakh smoking appears to exist most common, the history of midwakh and dokha use, and what is known about midwakh smoking from the published literature. On the basis of the stark lack of data on midwakh use, we suggest priority areas to focus futurity research. Preliminary data and observations from health providers and the public wellness sector propose that midwakh smoking may pose challenges to the tobacco control efforts in the Arabian Gulf region. If information technology is emerging equally a new ATP exterior this region, there could be a pregnant impact on tobacco control strategies globally.

  • Global health
  • Non-cigarette tobacco products
  • Prevention
  • Priority/special populations

This is an Open Access commodity distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 3.0) license, which permits others to distribute, remix, arrange, build upon this work non-commercially, and license their derivative works on dissimilar terms, provided the original work is properly cited and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/iii.0/

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  • Global health
  • Non-cigarette tobacco products
  • Prevention
  • Priority/special populations

Introduction

Tobacco use is pervasive worldwide, and it has profound health consequences for smokers and those exposed prenatally or to secondhand or third-manus smoke (SHS and THS).one Employ of tobacco remains among the leading contributors to the global burden of disease, accounting for more than 10% of this burden in 2010, and information technology is the leading preventable crusade of non-infectious disease deaths worldwide.1 ,2 Changes in clearing patterns have resulted in significant changes in demographic characteristics of many parts of the world. This, in turn, has resulted in the introduction and diffusion of what had previously been region-specific forms of tobacco and tobacco delivery systems to many new parts of the world.

The increasing apply of many such alternative tobacco products (ATPs) in areas that had non previously encountered them, coupled with the widespread implementation of public policies that have proven effective in limiting cigarette uptake and facilitating cessation of use, raises smashing business that these ATPs may replace cigarettes as major forms of tobacco commitment systems. Evidence of this growing concern is provided by the WHO'due south Global Youth and Adult Tobacco Surveys, the Canadian and US National Youth Tobacco Surveys equally well as the add-on of many relevant questions to the US Behavioural Chance Surveillance Arrangement Survey.3–vii While essentially increasing attending is being paid to some ATPs, such every bit hookahs (also called water pipes, used to smoke shisha), bidis (sparse, sometimes flavoured, cigarettes wrapped in the tendu or temburni leaf), kreteks (clove cigarettes), pan (betel quid with tobacco) and flavoured cigars and cigarillos, other ATPs of potential concern have to date largely been unrecognised and thus have non been studied, monitored or regulated.

This newspaper examines the apply of midwakh/dokha, an ATP which is widely used in the United Arab Emirates (UAE) and the Arabian Gulf Region, where its utilize is prevalent and growing in popularity. Brief indications, such as the proliferation of dokha websites and dokha sales at tobacco retailers internationally, propose that midwakh/dokha utilize could potentially emerge outside the Gulf region. If truthful, it may follow a pattern like to that of other ATPs such every bit hookahs, which accept translated from cultural/traditional employ in the Middle E to widespread global increases in use. Similar to hookahs, the marketing of midwakh/dokha is targeted at immature people.8–12

Tobacco use in the Arabian Gulf region

In the Middle East and specifically the Arabian Gulf region, cigarette smoking has warranted and garnered serious public health concern. Among adults in this region, the point prevalence of agile cigarette smoking was approximately 24% in men and <one% in women, according to i of the largest surveys of adult tobacco apply in the UAE.13 Further, it has been reported that 82% of students have tried their first cigarette before the historic period of 14.fourteen While exactly comparable metrics are not available globally, the following provides some context from other countries. Among regular cigarette smokers in the Britain, approximately 65% started smoking earlier the age of xviii years15 and in the USA, the mean age at which youth try their showtime cigarette is 15–16 years.16 The use of tobacco among those aged thirteen–xv years in the UAE is increasing every bit shown by the Global Youth Tobacco Surveys,17 ,18 which indicates that current smoking of any tobacco product increased from xviii% in 2002 to twenty% in 2005. While the use of cigarettes amongst those in this age group remained stable at 7–8%, the employ of ATPs such equally cigars, pipes, little cigars, chewing tobacco, snuff and dip increased from 18% in 2002 to 29% in 2005.17 Hookah use was reported by xi% of participants in both years.17 ,18 These data suggest that the increase in tobacco smoking prevalence amongst young adults in this region may be due in part to the increased utilise of other ATPs.

Tobacco control efforts in the Middle Due east and elsewhere continue to focus almost exclusively on curbing cigarette employ (including smoking cessation training of health and education professionals, media campaigns, increased taxation and banning tobacco smoking in public places), despite the alarming new research indicating increased use of ATPs. Additionally, there is as yet little evidence on success rates for quit programme methods for ATPs, such equally hookahs, which accept spread in global apply. The limited inquiry literature suggests that many ATPs may be as harmful as or even more harmful than cigarettes;19–24 yet, with respect to midwakh use, there is a critical lack of data on prevalence, attitudes, knowledge, toxicant exposure and health consequences.

What is midwakh and dokha?

Dokha (Arabic for 'featherbrained') is the tobacco blend that is smoked in a piping called a 'midwakh'. It is a combination of tobacco leaves with a variety of barks, herbs, spices, dried flowers or dried fruit, and is known for its loftier nicotine content, containing up to five times equally much as a normal cigarette.25 ,26 Dokha use originated in northern Iran in the 15th century8 and widespread use among sailors along the Caspian Sea resulted in its introduction into the Heart Due east in the 1500s.

The midwakh is used to inhale the fume of the burning dokha, and this pipage is structurally dissimilar from other Western smoking pipes (see figure i). Since the basin of the midwakh pipe is modest, it normally holds but ∼0.5 mg of dokha per use, thus requiring but 1–2 inhalations to fully burn the dokha earlier the pipage needs to be refilled.thirteen These two inhalations, however, may expose the smoker to nicotine and other tobacco constituents equal to or more than the exposure of cigarette inhalation.13 In that location is little data about comparative exposures betwixt dokha and other tobacco products, or the exposure to and furnishings of SHS and THS to dokha.

Since dokha tobacco is smoked almost exclusively in a midwakh pipe, its utilize is often referred to interchangeably equally dokha or midwakh utilize. In this paper, we will use the term 'midwakh utilise' or 'midwakh smoking' to represent the smoking of dokha tobacco in a midwakh pipe (and only refer to dokha when referring to the tobacco product itself).

Midwakh smoking is commonplace in parts of the Arab world and it appears to some that information technology may be growing in popularity (although no evidence equally of yet is available to substantiate this observation). We also believe that information technology is possible that midwakh smoking may emerge in Western countries among 'youth sub-cultures' based on the acceleration of websites selling midwakh and dokha and anecdotal observations of sales of midwakh and dokha in specialty stores in Western countries.8–12 Midwakh smoking (and the use of dokha tobacco) is the second most common form of tobacco used (after cigarettes) among men in Abu Dhabi in the UAE.13 Aside from hookahs, very fiddling is known nigh the utilize of other ATPs and culling tobacco commitment systems emanating from the Center East to other parts of the globe. The diffusion of the use of these products among the overall population is largely unknown, although near 20% of US adolescents study having used hookahs and more than 2% study having used bidis or kreteks earlier completing high schoolhouse.seven In contrast, nearly nothing is known about the use of midwakh in Western countries. This problem is compounded by the absenteeism of questions about it on any global or national tobacco survey outside the Arabian region. Despite this paucity of systematic public wellness data, numerous Northward American and European websites have emerged that market place midwakh smoking, especially to youth, as the 'the future of tobacco.'8 ,27 These websites emphasise midwakh smoking as: having 'more feeling', fourth dimension saving, less mess, odourless, economic, the newest trend and as a healthier option than cigarettes. The marketing message of midwakh utilise in the West is that of a trendy pastime and it has begun to announced on various merchandise items (figure two).

The potential emergence of midwakh in the West?

The result of globalisation and population mobility on public wellness is not a new concept.28 With dramatic changes in the demographics of Europe and Due north America, we believe that it is possible that the emergence of ATPs, such as hookah use, in the West is due, at least in part, to the clearing patterns and changing population demographics.29 ,30 With the popularity of midwakh use in the Gulf region, it is also possible for its use to gain popularity among immigrant populations in the West and transfer to native populations. Further, many of the current websites that sell dokha and midwakh are based in the USA or the UK.27 ,31 ,32 As suggested by these websites, there are many more shops and vendors in these Western countries that sell and market midwakh and dokha products. For example, on Medwakh.com, 238 retailers are listed across the USA that sell midwakh/dokha.32

There is a profound business concern near the use of ATPs in the USA, and the The states Food and Drug Administration (FDA) is now proposing new regulations including banning sales to those nether 18 and requiring disclosure of ingredients.33

While we cannot comment definitively on the emergence of midwakh in the West at a population level, its cultural popularity in the Arabian Gulf region and in similar communities in the Westward is becoming credible. American-based retailers of midwakh and dokha seem to have developed, at to the lowest degree in part, a clientele who have tried midwakh in the Arabian Gulf region and are interested in standing to use midwakh while living in the USA. Several quotes from an online retailer/forum illustrate this point31:Wassim J—Fairfax, VA: Dokha.com provides a service unmatchable past others in the US and provides nifty client service for all smoking needs. Information technology is a great place to social club from if you are similar me who has moved from Dubai to the U.s.a.… Alex C—Edison, NJ: Amazing that you tin get something soo skillful from afar then nearby. The delivery of the dokha is always within ii days of ordering and not once take i received stale dokha… Alp Cem—Sugarland, TX: Dokha.com is the easiest way to get Dokha in North America…I accept bought over twenty bottles from them and two pipes, it'south merely like the Dokha sellers back in the middle east. In case yous are like us, moved hither from the centre due east, don't fret, Mark (the owner of the store) has got you covered.

The demographics of Europe and North America are irresolute dramatically, with increasing numbers of immigrants from East and South Asia, Latin America and the Middle East. For example, over the past 2 decades, the immigrant population in the USA has increased steadily at a rate of ∼1 million per twelvemonth and at that place has been a dramatic shift in the national origin of immigrants. In the early on to mid 1900s, the majority of immigrants to Northward America were of European origin,34 while in 2010, 39% of immigrants to the USA were from Asia (including those emigrating from the Middle E),34 and in Canada 25% of immigrants were from Africa or the Center East. In Canada, the Eye Eastern population (West Asians and Arabs) constitutes the fastest growing immigrant group. Demographic trends of increasing global emigration hateful that regional public health concerns of ATPs such as midwakh smoking may translate to a serious global public health issue.

What is and is not known about midwakh employ

While a scattering of published studies suggest that the use of midwakh is mutual in the Gulf region,xiii ,35–37 the lack of data is striking. Nosotros conducted an electronic literature search by using the MEDLINE database of the National Library of Medicine, HealthSTAR and Google Scholar, from database inception until the cease of January 2013.. The search terms included: 'midwakh', 'medwakh', 'dokha' and 'Arab pipe'. Tabular array i provides a summary of the iv published studies on midwakh use that resulted from the search.

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Table 1

Summary of studies on midwakh employ

In the largest study published to engagement on midwakh use, Al-Houqani et al13 reported on a cantankerous-exclusive analysis of data apropos a nationally representative sample of 170 430 adult UAE nationals. Participants self-reported tobacco smoking habits via a questionnaire and data were nerveless over a 2-year period. Midwakh employ was the almost mutual tobacco product used later cigarettes, accounting for 15% of all tobacco smokers, and the users were predominantly men. Among midwakh users, on average, historic period was 30 years, elapsing of use was ix.3 years and frequency of use was 12 times per twenty-four hours. The authors ended that the utilise of midwakh, particularly given the young historic period of onset of use, is an important business organisation for public wellness activities and policy in Abu Dhabi. They as well expressed concern about the spread of midwakh apply to other countries.

In another smaller, cross-sectional study Jayakumary et al36 surveyed 104 students, aged 17–27 years, attending Gulf Medical University in Ajman, UAE. Thirty per cent of males and five% of females reported dokha use. Among dokha smokers, 33% smoked more than 100 times in their lifetime and 17% reported having smoked 26–100 times in their lifetime; 16% smoked more than 7–ten times per 24-hour interval during the by 30 days and 25% smoked on all days during the previous month. These findings are particularly alarming as they are derived from a select group of individuals training to exist physicians.

The 3rd study was a small pre–mail study with no controls conducted to assess the acute furnishings of smoking dokha.37 Study participants were 97 volunteer, male university students (Emiratis, other Arabs and other nationalities) who were consecutively sampled. The results were like to those found with other forms of smoking with mean increases in systolic blood pressures (12±1 mm Hg), eye rate (20±ii bpm) and respiratory charge per unit (4±1 breaths/min).

In a recently published study, the prevalence of midwakh use was assessed among developed Abu Dhabi marriage license applicants (using the Abu Dhabi Premarital Screening programme).35 All couples who apply for a marriage license are required to undergo several medical tests and complete a survey on behavioural risk factors. The data showed that, among men overall, the prevalence of midwakh smoking was 12%. By nationality, UAE nationals had the highest prevalence of midwakh utilise (16%), followed by Arab expatriates (iv%) and other expatriates (three%).

After reviewing the literature, it is clear that very little research has been carried out to explore the extent of midwakh utilize in population-based samples or the potential harms that may result from midwakh smoking. Just two studies were large enough to provide acceptable estimation of the prevalence of midwakh use (ranging from 12–15% in men). While the published scientific literature is meagre, anecdotally, according to practising healthcare providers, public health workers and the media, midwakh smoking is commonplace in the Arab Gulf region. Continued and expanded enquiry to better understand the problem of midwakh smoking is needed.

Future research priorities for midwakh use

Given the loftier reported prevalence of midwakh apply in the UAE and the almost complete lack of scientific and public data on midwakh use, there is a pressing need for more inquiry about this ATP. The primary purpose of this section is to suggest how nosotros can best expand and raise the existing body information on midwakh utilise. The primal volition be to start with the regions where studies can ostend that midwakh apply is a convincing public health result and using that every bit a basis to inform strategies to examine midwakh use outside of the Middle East.

Qualitative data from midwakh users

Personal accounts and marketing suggest that users believe that midwakh is a safer, more than convenient culling to cigarettes. All the same, the specific motivations of midwakh users are not known. Focus groups aimed at systematically assessing knowledge, beliefs, attitudes, run a risk perception, communication patterns, preferences, influences and modes of procurement tin provide insight into the behaviour of these users. It will too be of import to explore cultural dimensions of midwakh use, such as tradition, family and social norms. Results from these qualitative information will non just provide primal insight on midwakh users, but will also inform subsequent studies and encourage more focused inquiry questions for population-level observational studies of midwakh behaviours and related wellness outcomes. Understanding the factors that may be contributing to the ascent in midwakh use in the UAE and Arabian Gulf region is critical to developing accordingly tailored prevention, cessation and policy interventions. Additionally, understanding the differences, if whatever, between midwakh utilise in the Heart Eastward compared with the Due west may also exist key in curbing the spread of its use.

Other qualitative research that would provide important information regarding midwakh employ is a systematic search of websites representing retailers to written report on the content of data posted, customer comments and blogs, types of dokha for sale, and the price of dokha and midwakh. In a related study on hookah tobacco smoking establishments advertised on the net,38 it was plant that websites were spreading misinformation related to hookah employ. If this is similarly true regarding midwakh utilize, this misinformation needs to be countered with targeted wellness education and policy measures. These types of studies will also be important to document how individuals procure dokha tobacco.

Inclusion of midwakh employ in population-based surveys to improve understand the determinants, deterrents and distribution of its use.

In that location are many ongoing regional and global population-based studies on tobacco smoking habits in the Center E, including the Weqaya Cardiovascular Screening Programme (Abu Dhabi, UAE; 2008–2013),39 the Global Youth Tobacco Survey (UAE, Bahrain, Oman, Lebanese republic, Kuwait, Iran, Egypt; 2002 and 2005), the Global Adult Tobacco Survey (Arab republic of egypt; 2007) and the Global Wellness Professionals Survey (Egypt; 2005). Of these surveys, nevertheless, only the Weqaya Cardiovascular Screening Program has specifically reported on the use of midwakh. The Weqaya questionnaire (as reported in the paper by Al-Houqani et al13) used four key questions to assess midwakh prevalence: (ane) Do yous currently fume or have you e'er smoked midwakh/dokha? (2) How much do or did you lot fume midwakh/dokha per day? (3) How old were yous when you started using midwakh/dokha? (4) For how long have you lot or did y'all smoke midwakh/dokha? These questions provide information on the prevalence of midwakh use and serve equally of import baseline estimates. Since Weqaya is an ongoing screening programme, future analyses of trends in midwakh use over time will be possible. Further, these questions will provide a foundation on which to build more than nuanced and in-depth surveys. The current Global Youth Tobacco Survey being conducted in Abu Dhabi, UAE will too contain new questions about midwakh utilize; however, these data are not notwithstanding published. Improving the availability of information on midwakh use, exposure and related health outcomes through surveillance and monitoring volition be a key activity to assess its burden and identify population and time trends. It will exist important to do this using standardised evidence-based protocols and instruments; using representative samples; conducting surveys at regular intervals; and establishing the chapters to analyse and publish results. The inclusion of Gulf region countries in the WHO global tobacco-costless initiative volition also be a crucial task. In Western countries, such as the The states, Canada and Europe, the inclusion of specific questions on midwakh use in population-based surveys volition also exist key, focusing in particular on geographic areas with loftier concentrations of Heart Eastern immigrants.

Since decreases in the prevalence of tobacco utilise are oft preceded by a subtract in use amongst wellness professionals and other opinion leaders and early adopters of health-related behaviours, detail focus is needed to study the prevalence of midwakh apply among health professionals, public health officials and other professionals. Healthcare professionals are not only responsible for principal and specialty healthcare for tobacco related conditions, but they are also responsible for tobacco cessation counselling and treatment, and pedagogy regarding exposure to SHS and THS, in addition to serving every bit community role models.

The use of social media databanks to assess trends in midwakh use

Social media, such as Twitter and Facebook, allow users to share thoughts, opinions and random details of their lives. While many messages are of piddling value to wellness research, the aggregation of millions of messages can generate of import cognition, patterns and trends on a range of public wellness issues. For example, contempo work was able to correlate trends in Twitter messages that mention influenza with influenza rates equally documented by the Centers for Disease Control in the USA.xl ,41 Social media may also provide important information on wellness behaviours. Owing to the lack of available data on midwakh/dokha use, utilising data from social media information banks could provide new and important information on patterns of apply, geographic distribution, temporal trends and user perceptions. Such a written report could be conducted at minimal cost, and with relative immediacy.

Assessment of the effects of dokha use on cardiorespiratory and other systems

Tobacco employ has numerous, serious pathophysiological effects which may be immediate and brusque-lived or have more long-term consequences. The literature largely describes the furnishings of tobacco through cigarette use. The effects of other forms of tobacco apply may differ and the body of this enquiry literature is currently sparse. More studies on the result of dokha on the cardiorespiratory and other systems, specially compared with cigarette tobacco, are needed. Preliminary research36 (described to a higher place) has demonstrated that dokha had similar acute effects on blood pressure and respiratory rate as other forms of smoking; however, larger studies are needed that look at additional outcomes such as expired air carbon monoxide, blood carboxyhaemoglobin, cotinine and inflammatory marking levels, too as puff topography (a measure of astute smoking behaviour using a device to assess puff book, elapsing, number, peak flow charge per unit and interpuff interval). Anecdotal reports by smoking cessation physicians and users refer to firsthand dizziness after smoking dokha, implying a rapid physiological consequence. Studies suggest that other ATPs such as hookahs may take more than detrimental health effects than cigarettes.19–24 Currently, very footling is known about nicotine addiction among whatever ATP users.

Data on the economic aspects of midwakh apply

Agreement the economic aspect of a business or industry is an of import early on pace in developing benign public policies. Enormous profits have been made by the tobacco industry sacrificing public health and well-being, and leaving backside a serious economical burden and personal suffering.1 While economic inquiry has demonstrated the effectiveness of higher tobacco product taxes in reducing tobacco use, these methods are not effective for all countries. For case, the Gulf Council Countries apply a 100% tariff on importers' declared cost, insurance and freight value, yet the average price of cigarettes in the Gulf region remains lower than the average global price.42 With locally produced and inexpensive tobacco options such equally midwakh readily bachelor in the UAE, efforts to curb tobacco use become even more challenging. Additionally, when because the potentially changing patterns in tobacco use, and the rising of ATPs including midwakh use globally, it will be important to monitor their sales by region and by nation, distribution patterns and turn a profit margins. This can be washed, for example, by auditing a sample of retailers of dokha and midwakh, examining retailer characteristics and annual sales and comparing characteristics by region. By investigating the economical incentives and distributions of midwakh, researchers and policymakers alike will exist able to rail its pattern of consumption, motivations behind the sell and successful concern strategies. Consequently, policymakers will be able to programme more focused and effective interventions.

Conclusions

In the past decade, ATP utilise has been steadily increasing around the world. Far less is known about these tobacco products than about cigarettes, and the product for which the most data is known, namely hookahs, is however rudimentary. With a striking lack of data on almost all aspects of midwakh utilize, and the possibility of an increasing prevalence of a potentially more harmful form of tobacco, it is clear that immediate studies are needed. Investment in research and monitoring to empathise midwakh use in the Center Eastward is necessary to evaluate its potential public health threat. Midwakh use may have implications for public health programmes, policy initiatives and tobacco command worldwide.

Primal messages

  • The electric current manuscript consolidates and summarises the sparse torso of literature on midwakh smoking in the Middle East.

  • Authors postulate, through insights and opinions, on the threat of midwakh use to tobacco cessation efforts, too as its potential emergence globally.

  • This manuscript as well provides key recommendations with which to guide and prioritise future, needed, enquiry efforts on the public wellness effects of midwakh smoking.

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