Shisha smoking on the rise in student communities across Africa

Shisha smoking among university students across Sub-Saharan Africa is increasingly becoming fashionable, a habit that researchers say is being driven by aggressive marketing and advertising through social media platforms, and the availability of appealing and trendy designer flavours.

Unlike electronic and conventional cigarette smoking, shisha smoking is done through a ‘hookah’, a smoking device that uses coal, charcoal or wood to heat tobacco, enabling the smoke to pass through a chamber of water before being smoked through a hose.

Shisha smoking is the habit that is globally described as the waterpipe, narghile, arghile, ghalyan, or goza, and in some parts of South Africa as an ‘oka pyp’. The habit is commonly referred to as ‘hubbly bubbly’ smoking.

Originally, shisha contained tobacco that was typically mixed with molasses sugar. At present, many popular flavours include apple, strawberry, mint, coffee, honey, cola and vanilla. Other flavours of choice are cherry, chocolate, coconut, liquorice and watermelon.

South Africa

In a report, Prevalence of Use and Exposure of Young Adults to Electronic Cigarette and Hookah Advertisement and Marketing in South Africa, researchers at the South African Medical Research Council, or SAMRC, found that 31.5% of students smoked shisha.

Dr Catherine Egbe, a senior specialist scientist at SAMRC, noted that students in South African universities were heavily exposed to advertising and marketing of shisha through social media platforms, such as TikTok, Facebook, Instagram and X, the former Twitter.

“Our findings revealed that the majority of university students in South Africa were exposed to the advertising, promotion and marketing of hookah in and around university campuses and on the internet or social media,” said Egbe, the lead researcher of the study that was published earlier this year.

Additionally, Egbe said, university students in South Africa are also exposed to shisha smoking in bars, cafes, nightclubs, restaurants and taverns where hookah smoking devices can be rented.

In her other remarks, Egbe said shisha bars are popular around university campuses in South Africa, while the paraphernalia for hookah smoking is sold in strategic locations in shopping malls around the country.

Nigeria

Similar situations appear to occur in Nigeria, where Dr Noreen Dadirai Mdege, a senior research fellow at the University of York in the United Kingdom, and other researchers estimate that between 3% and 7% of secondary school and university students in Nigeria smoke shisha.

In the study, ‘Reasons for shisha smoking: Findings from a mixed methods study among adult shisha smokers in Nigeria’, published in the journal PLOS Global Public Health earlier in 2024, Mdege and associates highlighted that shisha smoking has increased significantly among university students in Nigeria because of its easy accessibility in social places such as clubs, bars, pubs, cafes, restaurants, markets, and convenience stores.

Their findings are consistent with those of Victor Olufolahan Lasebikan, a professor of psychiatry and addiction medicine at the University of Ibadan in Nigeria, who found that shisha was spreading rapidly among university undergraduates in Nigeria and other adolescents.

Two years ago, Dr Uwaila Otakhoigbogie, a consultant oral physician at the University of Nigeria teaching hospital in Enugu, and his fellow researchers found that, of the 546 university students who studied at the University of Port Harcourt in Nigeria, 24.7% had smoked shisha.

In the study, ‘Knowledge and Sociodemographic Predictors of Shisha Smoking Among Students in a Nigerian University’, published in the Nigerian Journal of Clinical Practice, Otakhoigbogie and his group of researchers found that the smoking of shisha was highly influenced by the level of study, type of faculty and poor knowledge of the ingredients used and their harmful effects.

Cameroon and beyond

Researchers undertaking research among students in four tertiary institutions in the city of Buea in Cameroon recently found that the prevalence rate of smoking shisha was at 26.%, while 23% of the students had poor knowledge about its harmful health effects.

“Our conclusion was [that] shisha smoking was becoming highly prevalent among tertiary students in Cameroon,” said Bertrand Mbatchou Ngahane, an associate professor of internal medicine at the University of Douala, in a study, ‘Prevalence, knowledge and factors associated with shisha smoking among university students in Cameroon’, that he and others published in August last year.

Subsequently, widespread smoking of shisha among university students has been reported in Djibouti, Ethiopia, Ghana, Kenya, Rwanda, Tanzania and Uganda, among other African countries. In most countries in Sub-Saharan Africa, shisha smoking facilities are imported from Egypt, Turkey, India and other countries where the manufacture of hookah devices has a long and rich cultural history.

Disregarding the risks

In the event, university researchers in Sub-Saharan Africa appear to be worried about rising trends of shisha smoking among university students and the total disregard for the risks involved.

Two academics, Elizabeth Lubinga, a professor of strategic communication at the University of Johannesburg and Aniekie Motloutsi, a communication specialist at the University of Zululand, say the risks for shisha smoking are high.

“Due to shisha’s long smoking duration that results in greater nicotine exposure, shisha smoking presents more harm to users than its much-publicised ‘cousin’, cigarette smoking,” said the two researchers in their study, ‘Assessing awareness, knowledge, and perceptions of hubbly bubbly smoking health risks among South African university students’, that was published last year in the communication studies journal Communicare.

They pointed out that the alluring and mystical appeal associated with shisha smoking, is a risk factor for oral cancer, periodontal diseases, the staining of teeth and oral tissues, bad taste and bad breath.

But, much worse, oral physician and researcher Otakhoigbogie stated that hubbly bubbly or water-pipe smoking has been implicated as a risk factor for tobacco-related diseases such as lung cancer, oesophageal cancers, cardiovascular disease and adverse pregnancy outcomes.

“Quite erroneously, unlike cigarette smoking, shisha is believed to be less irritating with a less adverse effect on the lining of the oral cavity, while the fruit juice flavours added to shisha are also believed to be good for health,” he said.

According to Otakhoigbogie, there are also indicators that water-pipe smoking can be associated with communicable diseases such as hepatitis C and tuberculosis, resulting from shared mouthpieces and repetitive use without disinfection, in addition to toxins from burned coal.

But, despite those high risks, addiction medicine and psychiatry specialist Lasebikan highlighted that shisha smoking among students in Sub-Saharan Africa is driven by the perception of it being less addictive than cigarette smoking, as well as it being seen as a fashionable symbol.

According to the United States Centers for Disease Control and Prevention, or CDC, shisha smoking is not a safe alternative to smoking cigarettes, as the charcoal or coal used to heat the tobacco can increase health risks by producing high levels of carbon monoxide, metals and cancer-causing chemicals. The issue is that, even after it has passed through water, the smoke from a hookah has high levels of toxic agents that are known to cause lung, bladder, and oral cancers, says the CDC.

In a public health-promoting briefing, the CDC stressed that smoking shisha has more adverse risks than smoking cigarettes because of the intensity and duration of smoking shisha. “In a typical one-hour hookah smoking session, users may inhale 100–200 times the amount of smoke they would inhale from a single cigarette,” stated the briefing.

The CDC says that, in a single shisha session, users are also exposed to up to nine times the carbon monoxide and 1.7 times the nicotine of a single cigarette, while the amount of smoke inhaled during a typical hookah session is about 90,000 millilitres (ml), compared with 500-600ml inhaled when smoking a cigarette.

Indeed, such overwhelming statistics show large numbers of university students in Sub-Saharan Africa have been exposing themselves to a high burden of disease by smoking different variants of shisha.

The emerging studies on the issue indicate that most students in many countries are not aware of the risks of smoking shisha in comparison to alcoholism or excessive smoking of cigarettes.

Should shisha smoking be banned?

As a result of its popularity, shisha smoking may be banned in countries such as the Gambia, Ghana, Kenya, Rwanda, Tanzania and Uganda, but its use is spreading underground, according to the World Health Organization.

The issue of shisha smoking is worrisome in that most students are not aware of the overriding health and cognitive ability consequences. According to researchers, about 50% of students are exposed to the habit through aggressive marketing and advertising as well as its easier availability near their institutions.

Even assuming that only 20% of students are hooked on smoking shisha in Sub-Saharan Africa, then it would mean that 1.8 million students are already addicted as, according to the United Nations Educational Scientific and Cultural Organisation, or UNESCO, the region currently has about nine million tertiary students.

As the SAMRC’s Egbe pointed out, the looming danger is that most university students remain unprotected from the advertising and marketing tactics of the tobacco and nicotine industries – not just in South Africa, but in most countries in Sub-Saharan Africa.

In that case, the recent studies on shisha smoking and alcoholism among university students in the region call for appropriate measures to be put in place to protect young people from being targeted and recruited as the next generation of those addicted to nicotine or alcohol.