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World No Tobacco Day; Health risks of Shisha and other tobacco products.


May 31st is World No Tobacco Day and thus an important date on the World Health Organization and Ministry of Health, Uganda calendar.

The extent of the human and economic burden that results from tobacco use is jaw dropping. Globally, tobacco kills more than 8 million people per year with over 7 million of these deaths resulting from direct use of tobacco and approximately 1.2 million as a result of exposure to second-hand smoke by non-smokers.

In the African region, approximately 146,000 adults aged 30 years and above die every year from tobacco-related diseases. About 80% of the 1.3 billion tobacco users globally reside in low and middle-income countries, these are countries where tobacco-related illnesses and deaths are heaviest. 


According to the WHO Global Health Observatory Data-2016, the average life expectancy at birth of the global population is 72 years and 62.5 for Uganda. There is a high prevalence of tobacco use in Uganda, studies show that 1 in 10 adults use tobacco products daily.

There has been a notable global shift in causes of morbidity and mortality from infectious diseases (such as malaria, pneumonia and HIV) to Non Communicable Diseases(NCDs) such as Cancer, Diabetes and Hypertension. In 2018 when WHO commemorated World No Tobacco Day, The Minister of State for Health in charge of Primary Health Care, Dr. Joyce Kaducu Moriku did mention that tobacco affects the heart gravely, with 12 percent of all heart-related deaths related to passive smoking. She emphasized the need to stop tobacco consumption. 


WHO’s Global Status report on Non Communicable Diseases (NCDs) indicated that tobacco use has been the main risk factor for NCDs which we now know account for 25% of all the deaths in the country. Research conducted at Uganda Cancer Institute also showed that 25% of patients who suffered from lung cancer were tobacco users, 16% oral cancer, 13.7% stomach cancer and 12.6% throat cancer, all these patients were tobacco users.

On average, the life expectancy of a smoker is 10 years less than a nonsmoker. It has been established that cigarette smoke contains more than 7,000 chemicals, 70 of which are known to cause cancer of the head, neck, throat, oesophagus and oral cavity (mouth, tongue, lip and gums) as well as various dental diseases and more recently recognized by chest physicians to significantly contribute to risk of infection and severity of COVID 19.

Tobacco is a household name for a number of plants in the Nicotiana genus and the Solanaceae family. It is a potentially addictive substance, and a gateway for most people that become addicts in later life, despite the negative consequences in the long term. Conversely, compared to other substance of abuse, legally acceptable substances such as tobacco and alcohol are medically far more harmful if used in non-over-dose amounts compared to illegal drugs such as marijuana. And again this is no justification for illicit drug use if we must take up a well thought drug prevention strategy.

Data from the WHO suggests that tobacco use contributes to poverty through diversion of household income from basic needs such as food, shelter to tobacco.To add insult to injury, there is significant impact of tobacco use on the economy. The health care costs for treating the complications of diseases that result from its chronic use such as cancer, straining already struggling health systems, the lost human capital resulting from tobacco-related deaths notwithstanding.


According WHO all forms of tobacco are harmful and there is no caveat for a safe level of exposure to tobacco. So far, cigarette smoking is the common form worldwide. Other tobacco products include cigars, cigarillo, roll-your-own tobacco, pipe tobacco.


Lately, there is a growing fancy trend of emerging Heated Tobacco Products (HTPs), the devices heat the tobacco within a very specific temperature range, the electronic heat-control system prevents it from burning, by contract, e-cigarettes (aka Electronic Nicotine Delivery Systems-ENDS and Non Nicotine Delivery Systems) vaporize a liquid containing flavorings and sometimes nicotine, depending on the type. ENDS contains varying amounts of nicotine and harmful chemicals which are not safe especially for children and young adults whose brains continue to develop up to about 25 years age as well as damaging the growing baby if used by a pregnant woman. They have been promoted as an alternative to conventional smoking and having reduced harm. However, these equally contain toxic chemicals that cause cancer and there is no sufficient evidence to suggest they are less harmful than conventional cigarettes.

Different forms of tobacco

  1. Waterpipe tobacco - In Uganda, it is also known as Shisha/hookah.

It is an ancient practice that started in India. It involves passing tobacco smoke through water prior to inhalation by the individual consuming it. The danger lies on misconceptions, a deeply held belief that it is free from health hazards. Contrary to popular belief, it is associated with adverse health outcomes on both short and long-term basis. The smoke that emerges out contains toxicants known to cause lung cancer, heart disease and other diseases. A good number of pubs in Kampala sell Shisha.

Waterpipe sessions may expose you to more smoke over longer period of time, than when smoking a cigarette. According to CDC, cigarette smokers take about 8 to 12, 40 to 75 ml puffs in over 6 minutes, therefore inhaling approximately 0.5 to 0.6 litres of smoke. Interestingly, Shisha sessions for example last 20 to 80 minutes, during this time, a smoker may take 50 to 200 puffs, which range from 0.15 to 1 litre each. Therefore, a Shisha smoker will inhale as much smoke during one session as a cigarette smoker would inhale, consuming 100 or more cigarettes. The dangers of waterpipes are not well understood by users.

Summary of key facts.

  • 1-hour long Shisha smoking session for example is equivalent to inhaling a volume of 100 – 200 times the volume of smoke inhaled with one cigarette or in simple terms this means that, it is equivalent to smoking about 100 to 200 cigarettes.

  • The charcoal used to generate heat produces its own intoxicants such as carbon monoxide, cancer-causing chemicals and metals.

  • There is no proof that the accessories used make this practice less harmful. Do not be deceived by individuals advertising these waterpipes.

  • Sharing a waterpipe mouthpiece increases the risk of transmission of diseases as such Covid-19, tuberculosis and hepatitis.

Second-hand smoke from these pipes is a mixture of tobacco smoke, and the smoke from charcoal used as a source of fuel. A combination of this will pose a serious risk to the non-smokers.

      2. Smokeless tobacco products

These are tobacco products that do not need to be burnt; they can be chewed, snuffed, sucked, spat or swallowed depending on how it is made. Some companies are making flavored forms that maybe appeal to young people.

Other tobacco products that are not combustible include those that are finely ground and pressed to form tablets, sticks, or even strips. Some companies make them look attractive; like candy bars or small mints and can be confused for ordinary chewing gum.

  1. Cigars

It is worth noting that cigars are not a safe alternative to cigarettes. You will still be at risk of getting mouth, throat and lung cancer not forgetting heart disease. They contain the same addictive, toxic and cancer-causing chemicals found in cigarettes. These smokers are 4 times more likely to suffer and die from cancer. A cigarette contains approximately 1 to 2 milligrams of nicotine, while a cigar contains 100 to 200 milligrams, some cigars have 400 milligrams of nicotine. Cigar smoke is more concentrated.


  1. Cigarillos

 These are the ones that are wrapped in tobacco leaves or a brown tobacco-based paper, and are relatively smaller than the cigars


  1. Roll-Your-Own tobacco

They are not safer either. This is tobacco that is loose, and the user can put it inside the rolling paper and burns. It is also known as 'the combustible tobacco'.


  1. Pipe tobacco

This is also a combustible tobacco product; it is basically loose tobacco placed in a traditional smoking pipe.  It is not a safer alternative. An average smoking bowl will contain about 1 to 3 grams of tobacco. The nicotine level per gram is approximately 30 to 50 milligrams.


  1. Bidis

This is also a combustible tobacco product, meaning it can be burnt as the user consumes it. They are small, thin, hand-rolled tiny cigarettes Some are flavored (E.g. chocolate, cherry, mango) other are not flavored. It increases the risk of getting oral cancer, lung cancer, esophageal cancer and stomach cancer. Studies show that they have a higher concentration of nicotine that normal cigarettes.


  1. Kreteks

This type is not commonly used. There is little research done due to the low prevalence. CDC reports that Kretek is associated with lung damage which can result into very low oxygen, and a lot of fluid in the lungs especially among people living with asthma.


Health benefits of quitting and what you can do to quit.

Among smokers who are aware of the dangers of tobacco, the vast majority want to quit but do not know where to start from. Counseling and medication have been proven to double the chances of quitting. Intense advice from the experts goes a long way.

Quitting reduces your chances of becoming impotent, difficulty getting pregnant, having premature babies, and giving birth to babies with very low birth weights including miscarriages.


This is what happens when you quit;

  • Within 20 minutes of quitting, your blood pressure and heart rate drops.

  • After 12 hours, the carbon monoxide level in your blood also drops to normal.

  • 2 to 12 weeks of quitting, your lung health dramatically improves, including the normal flow of blood in your body.

  • 1 to 9 months, there is reduction in cough and shortness of breath.

  • After a year, the risk of getting heart disease such as coronary heart disease drops by half.

  • 5 years later, your risk of getting stroke is reduced.

  • 10 years later, your risk of lung cancer, drops to approximately half that of a smoker, and the risk of getting oral, throat, stomach, and esophageal cancer drops.

I encourage you to be the best advocates for your own health. Quitting is a journey, it is tough but worth it. Prepare for the day you decide to quit, speak to a healthcare provider (a nurse or any other health practitioner) and find an addiction specialist.

HOW DO WE REDUCE TOBACCO DEMAND?

  • Public display of health warnings has been shown to work as a deterrent for smoking by significantly increasing people’s awareness of the harms from tobacco use.

  • Mass media campaigns through social and print media can also promote the protection of nonsmokers and help convince people to stop or better still quit smoking.

  • The government through public health policy can levy high taxes on tobacco as a control measure. The government should also ban tobacco advertisement on television and radio as well as print media.

  • Because tobacco is a potentially addictive substance, there is need to offer psycho-social support to help people quit tobacco.

REFERENCES

1. Tobacco use and associated factors among Adults in Uganda: Findings from a nationwide survey

2. Uganda's Ministry of Health calls for an end to Tobacco use

3. WHO: E-cigarettes

4. Health benefits of smoking cessation

5. Advisory Note. Waterpipe Tobacco Smoking: Health effects, Research Needs, and Recommended Actions by Regulators (PDF)

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