Quitting Camel Country
Dokha, shisha, vapes: THR in the Middle East region
By Cheryl K. Olson
Tobacco has been part of daily life in the Middle East since the 1600s. An archeology journal describes excavations in Istanbul uncovering “massive numbers” of broken clay tobacco pipes from the centuries before the rise of cigarettes. Some of the highest smoking rates in the world are found in Middle East nations. Over half of men in Jordan smoke, for example.
“The Middle East has got an extremely long culture in terms of smoking. That’s going to be really hard to turn round,” says Harry Shapiro, a U.K.-based educator who reports on global tobacco harm reduction. Based on data from the World Health Organization, smoking was projected to decrease among men in the region by less than 2 percentage points, from 33.1 percent in 2010 to 31.2 percent in 2025.
Most of the top causes of death in countries in the region are either caused or worsened by smoking. New approaches are urgently needed. Yet there is a frustrating lack of information on where and how to start. A 2024 WHO report on global tobacco use trends notes that data in the Eastern Mediterranean region “are the least robust,” i.e., limited or outdated.
What’s different about the Middle East when it comes to tobacco use? What’s the need for tobacco harm reduction? And what factors might support or block the uptake of reduced-risk products?
Shisha, Dokha, Shammah
A U.S. university professor who has studied tobacco use trends in the region (and asked to remain anonymous) shared his local experiences and findings with me. One issue he faced was collecting information on reduced-harm products not yet authorized by regulators. Given Middle East government policies, researchers can’t ask questions about illegal behaviors. “I could be compelled to give individual-level data regardless of what people signed about confidentiality,” he said.
After the United Arab Emirates legalized e-cigarettes, his surveys found that vapes were widely used. “People shifted back and forth between cigarettes, e-cigarettes and a local tobacco called dokha, which means “dizzy.” Because you can inhale the equivalent of one cigarette’s worth in one or two quick puffs,” he said (see “Old School, Modern Market,” Tobacco Reporter, August 2014.)
Tobacco use in the Middle East has largely centered on three products. Cigarettes currently dominate, with use rates hovering around 30 percent for men. In most of the region, smoking is culturally unacceptable for women. Given the reluctance to admit to smoking, reported female use rates of about 2 percent may in reality be several times higher. In Lebanon, the professor noted, women can openly smoke. There, use rates are around 30 percent for both genders. Concerningly, his colleagues in that country feel that Lebanon is the tobacco use trendsetter for the region.
A second popular regional product is shisha tobacco, smoked through a water pipe or hookah. Use reportedly increased in the 1990s when flavored products emerged. “Previously, it was mostly grizzled old men in coffee shops,” the professor noted, “but the new products weren’t harsh or unpleasant in taste and became trendy among young people.” A 2020 review of research found “alarmingly high” use among university students in the region, including by women.
Hookah smoking is a social activity. A college student in Abu Dhabi might go out with friends and smoke hookah once or twice a week or once per month. However, some users are addicted and will smoke daily.
What sets shisha apart is the communal pipe. “There might be multiple hoses, but you’re still breathing through the same water and sharing germs,” the U.S. professor noted. “A session might go on for an hour and generate the same volume of smoke as five packs of cigarettes.” This means exposure to a huge quantity of smoke, even at the secondhand level. Even worse? Inhaling toxins and carbon monoxide from the charcoal burned to heat the waterpipe.
Finally, there is dokha. This powdered tobacco comes in different varieties and strengths and is often mixed with herbs, spices and other substances. Dokha is smoked in a small pipe (usually wooden) called a midwakh. Some users perceive it as a safer alternative to smoking, but the limited research suggests that dokha may give off more toxins than cigarettes. Despite dokha being as common as cigarettes in countries such as the UAE, published studies on dokha use, effects and cessation have been rare.
A regional oral tobacco product also merits mention and more study. Shammah is reportedly common in Saudi Arabia and Yemen. Locally made by mixing ground tobacco leaf with flavorings (including lime, ash, black pepper and oils), shammah contains a variety of potential carcinogens, including nitrosamines.
Reducing Risk
Several countries in the Middle East (such as Iran, Oman and Qatar) still ban e-cigarettes, and others (e.g., Saudi Arabia) ban snus. But in general, the region has bucked the global trend, loosening regulations on vaping and heated-tobacco products. Nicotine pouches are largely unregulated. (See the Global State of Tobacco Harm Reduction website, GSTHR.org, for country-by-country information.)
More research is critically needed to help channel information and support to those Middle Eastern subgroups most endangered by their tobacco use behaviors. University students who occasionally smoke shisha, for example, likely face minimal risk.
Most evidence on vaping originates from North America and Europe. As a recent paper on e-cigarettes in the Middle East points out, studies within the region suffer from “overreliance on university-based samples, the overuse of non-user samples, a lack of studies on behavior change, high variance in existing data and a lack of uniform instruments to measure e-cigarette use.”
Shisha is a good example of the need for cultural sensitivity in promoting smoking cessation or a switch to less risky alternatives. “For hookah, people smoke very much for the social reason. It’s a social construct, not an addiction construct,” said the U.S. professor. “Most cessation interventions have not really worked because most have thought about hookah like cigarettes, with nicotine-replacement therapy and counseling.”
As one college student in the UAE told him, “People don’t drink alcohol here. There are no drugs. We need a way to hang out with our friends.” Effective reduced-risk substitutes for waterpipe smoking must deliver that.
Companies have begun creating reduced-harm products specifically for Middle East countries.
For example, Dubai-based ANDS (short for alternative nicotine-delivery solutions) makes vaping and heated-tobacco products. A company called OOKA has developed a charcoal-free shisha device. Philip Morris International recently acquired a stake in Eastern Co., Egypt’s largest tobacco producer, with a stated goal of providing alternatives to cigarettes for adults who smoke.
New technologies can make an attractive contrast to smelly old-fashioned cigarettes. “A lot of the vaping devices are really quite geeky—like a fancy electronic gadget that happens to deliver nicotine,” notes Shapiro. “They have touch-screens, and you can chart use on your laptop. So that’s likely to appeal to the younger generation of more wealthy urban groups” in the region. However, such products are likely to reach few lower income or rural people who smoke.
Shapiro notes that two things are necessary for reduced-harm nicotine to gain a foothold and start displacing cigarettes. First, “Governments have got to be prepared to get tough on smoking: banning smoking in public areas and such.” Second, there needs to be proportionate promotion of novel products, including lower taxes versus cigarettes, and education that supports the option of harm reduction alongside cessation. As a recent Lancet commentary (by former WHO leadership) notes, “In some countries, substantial reductions in smoking prevalence have coincided with novel nicotine products.”
“If a country does ban safer nicotine products, look at how much it relies on the tobacco industry—in terms of revenue from taxation or whether the country grows tobacco or exports it,” says Shapiro. “If state regulation is sympathetic, then these products will find a way into the shops.”
The presence of the World Vape Show in Dubai, starting in 2021, sent a message that these alternatives could be acceptable. I will be part of two panels at the 2024 Global Vape Forum, which accompanies this year’s Dubai vape expo. We will stress the need to save lives by moving people off combustible tobacco, whether through cessation or switching to reduced-risk products.
Getting doctors on board with harm reduction is another important step. Like their colleagues around the globe, Middle Eastern physicians frequently misperceive nicotine as the cause of cancer and other health risks of tobacco. Region-specific studies of doctors’ perceptions and needs are essential. I could locate only one small study. A 2019 Egyptian survey found that doctors were aware of e-cigarettes but viewed them less positively than their patients.
References
Al-Hamdani M, Hopkins DB (2023). E-cigarettes in the Middle East: The known, unknown, and what needs to be known next. Preventive Medicine Reports. https://doi.org/10.1016/j.pmedr.2022.102089
Beaglehole R, Bonita R (2024). Harnessing tobacco harm reduction. The Lancet. https://doi.org/10.1016/S0140-6736(24)00140-5
Fouad H, Commar A, Hamadeh RR et al. Smoking prevalence in the Eastern Mediterranean region. Eastern Mediterranean Health Journal. 2020;26:1. www.emro.who.int/emhj-volume-26-2020/volume-26-issue-1/smoking-prevalence-in-the-eastern-mediterranean-region.html
Nasser AMA, Geng Y, Al-Wesabi SA (2020). The prevalence of smoking (cigarette and waterpipe) among university students in some Arab countries: A systematic review. Asian Pacific Journal of Cancer Prevention. https://journal.waocp.org/article_88992.html
Samara F, Alam IA, ElSayed Y (2021). Midwakh: Assessment of levels of carcinogenic polycyclic aromatic hydrocarbons and nicotine in dokha tobacco smoke. Journal of Analytical Toxicology. https://doi.org/10.1093/jat/bkab012
Raj AT et al (2019). Systematic reviews and meta-analyses of smokeless tobacco products should include shammah. Nicotine and Tobacco Research. https://doi.org/10.1093/ntr/nty144
