Muslim Charities & Charity Commission

The month of Ramadan is finally upon us. It is a time in which we can grow closer to our Creator, primarily through the noble acts of fasting and by occupying our time with the performance of beneficial acts of worship such as prayer, recitation and giving charity to organisations which aim to further the Islamic cause.

The drive for fundraising from Muslim charities is clearly visible during the blessed month. Prime time on all Muslim television stations will be dominated by charity appeals, the continuous barrage of emails and pamphlets through the door and not to forget the reminders on social media (and don’t forget to hit the ‘like’ button!). We see charities, both the well known as those whom we have never heard of before, telling us of all the fantastic work they are doing in the UK and abroad in helping needy Muslims. Frequently, the appeals touch our hearts, and it is from amongst the blessings of Allah that the Muslim community donates in an almost carefree fashion in the month of Ramadan.

Whilst our intention first and foremost should be to seek the pleasure of Allah through our sadaqah, perhaps it is important for us to question what happens to the money we have donated? Are charities really doing the work they claim to do? Whilst we certainly shouldn’t doubt an organisation for no apparent reason, I believe we should primarily aim to support those organisations which clearly have a track record in spending charitable funds in a wise manner and alongside this, have gone to the trouble of making their accounts crystal clear for the public to see.

All registered charities are regulated by the charity commission, and charities have a duty to provide their annual accounts to the commission. The accounts need to be audited by an independent firm which has no affiliation to the charity in question. The accounts are then made available on the charity commission website for the public to see how a charity spends its income (http://www.charity-commission.gov.uk/). Not only do such procedures act as a deterrent to foul play within charities, they also give the public confidence to donate to those charities which have demonstrated clarity in their affairs.

Whilst it is very encouraging to see many well-known Muslim charities providing their accounts, a small number have submitted sparse amounts of information. One well known organisation has failed to provide any accounts for the last 4 years, whilst another has only been registered since the end of 2011, despite the fact that it has been fundraising for the last 4 years! Although this does not in any way imply that these charities have been partaking in foul play, such actions are highly unprofessional. In addition, failure to provide details of financials can be seen as disrespectful to those giving money to these charities. The least these charities can do is inform their donors what they have been doing with the money which has so generously been given to them through clear, independently verified accounts.  

In light of this, I advise Muslims to do a bit of homework this Ramadan prior to donating their sadaqah and zakat by taking part in the following steps:

1. Find out if the charity has a proven track record in seeing through its projects. Did they really do what they claimed they would?
2. Ask other Muslims what they know of the charity in question. Word of mouth is a very powerful medium. 
3. Check the charity on the charity commission website. See if they are registered, and check if they have provided their accounts for public viewing. Charities which have failed to provide up to date details shouldn’t receive public donations, unless of course they are able to explain in a satisfactory manner the reasons for not providing these details. 
4. Those charities which have been clear in their finances and have built up a sound reputation for doing good work should receive generous donations. They should be encouraged to continue their excellent work, and perhaps we should donate even more to them than what we usually would.

If we collectively take such an approach to our sadaqah, it will encourage better standards amongst Muslim charities. Such a simple act of ‘self-regulation’ will make the collective body of Muslim charities much stronger, which will ultimately have benefits to the worthy causes in which they operate.

Assisted Suicide – Another Battleground for the Atheists versus Theists

Introduction

There has been a growing call in the United Kingdom to legalise the act of ‘assisted suicide’, where the death of a terminally ill patient is moved along with the assistance of another individual on grounds of compassion. Earlier this month the Faulkner report concluded that there is a strong case to allow assisted suicide for terminally ill patients in England and Wales^[1]. This report was funded by Sir Terry Pratchett who himself suffers with Alzheimer’s disease and has been actively campaigning for a change in legislation since his diagnosis. 

The findings of this commission have re-ignited the debate on assisted suicide. There is a growing sentiment amongst the public to see a change in legislation, highlighted by a number of polls on the subject which regularly show that almost three quarters of the population want some form of legislation to allow assisted suicide. Doctors, however, are more divided on the issue which comes as no surprise since they’re trained with the mindset of preserving life.^[2] Moreover, as the primary agents for healthcare delivery, doctors are very well placed to identify causes for concern in changing the legislation that the general public may be oblivious to, which may further explain the disparity in poll results.

Summary of the Arguments

It is important to understand the difference between euthanasia and assisted suicide. With euthanasia, a doctor initiates a causal sequence of events resulting in the death of the patient. In the case of assisted suicide, the doctor may either help or fail to prevent a patient completing a course of action which results in their death. In the former case, the doctor is in control whereas in the latter situation the patient remains the agent, although this boundary may be somewhat blurred.   

The argument for those who call for assisted suicide to be legalised centres around the concepts of easing suffering and quality of life. In chronic degenerative conditions such as motor neurone disease and Alzheimer’s disease, patients experience a gradual loss of normal physiological function which ultimately results in their quality of life being severely impaired. For example, such patients may need to be fed artificially and may not be able to go the toilet independently consequently soiling themselves, and they may be completely bedbound to name but a few of the major factors lowering their quality of life. These patients eventually require substantial packages of care to keep them alive with intensive medical and nursing support. With so much resource going into ‘prolonging’ the life of an individual with such an apparently poor quality of life, proponents of assisted suicide argue that such patients should have the right to terminate their life prematurely so that they may die with ‘dignity’.  

Those who are opposed to the notion of assisted suicide raise legitimate concerns about the execution of such a practice and argue that its legalisation may ultimately lead to more harm within society. The issue of regulation is one which is frequently mentioned by anti-assisted suicide groups; what steps will be taken to ensure that assisted suicide is properly executed and how, if at all possible, will we be able to determine if foul play has been involved at any stage? Moreover, is it really possible for a patient to make a truly autonomous decision on their wish to opt for an assisted suicide? In his article, Andrew Warnock argues that assisted suicide can never be an autonomous decision, as once a loved one’s opinion is called into the matter, so are their interests^[3]. This opens up the possibility of vulnerable adults being coerced into making the decision to take their life for the gain of others, leading the British Medical Association to conclude that the opportunities for manipulation and abuse in such a situation would be ‘unacceptable’. In addition, the BMA argues that the legalisation of assisted suicide may alter public perception of the weak, the chronically ill and the mentally impaired and perhaps their worth may be devalued[4]. This is a potentially dangerous situation, especially when one takes into account that as legislation currently stands there are frequent reports about the physical and mental abuse vulnerable adults go through.

The Members of the Debate

The public debate on assisted usually suicide is yet another battleground for the godless and the God-fearing. The Church of England has recently maintained its stance of being against assisted suicide, by condemning the findings of the Faulkner report^[5]. They accused the commission of bias, highlighting that the commission was made up of self appointed individuals and excluded people known to be against assisted suicide, and they further reiterated the concerns surrounding the safeguarding of vulnerable adults within the proposed change in legislation. Other religious groups, including the UK Muslim community, are yet to officially comment on the findings of this commission. 

The central reason for atheists to strongly support assisted suicide stems from one of the key arguments they use to prove the non-existence of God. After all, how can a compassionate, merciful God allow people to experience intense pain and suffering through chronic medical conditions? They reason that if there really was an all merciful Creator, he would never allow us to undergo such suffering.

Unfortunately when the devoutly religious argue against assisted suicide, they tend to focus their argument on issues of regulation and the potential for harm. Whilst these are important points, they fail to discuss the crux of the issue that assisted suicide goes totally against the commandments of God unto mankind.  Perhaps they feel ashamed to make this point in public, as the belief in a supreme creator continues to be heavily caricaturised in the increasingly secular media. Thus, were they to base their argument around this point, it would be portrayed as crass comedy as opposed to being viewed as a legitimate response to proponents of assisted suicide.

The fact that theists feel they cannot focus their argument on this central point illustrates the uphill task they have in convincing the secular public on the arguments against assisted suicide. Rather than discussing the legal intricacies of assisted suicide, faith groups need to be bold in their response that assisted suicide goes against what God has ordained for man. However, such an argument can only be effective if there is a continual effort from theists to convince the general public in the existence of an all powerful God.    

The Muslim Stance

The concept of assisted suicide is something strictly against the principles of Islam. This is illustrated through a number of texts:

Do not kill yourselves, for verily Allah has been to you most merciful^[6]

…take not life which Allah has made sacred”^[7]

There is also a Prophetic tradition referring to the grave sin of hastening one’s death for medical reasons. It was narrated by Jundub that Allah’s Apostle said,

“Amongst the nations before you there was a man who got a wound, and growing impatient (with its pain), he took a knife and cut his hand with it and the blood did not stop till he died. Allah said, ‘My Slave hurried to bring death upon himself so I have forbidden him (to enter) Paradise”^[8]

Muslims believe that the reason God created life and death was to test mankind and thus any hardships man faces are a means for God to test his creation. Moreover, if someone patiently perseveres with a hardship understanding that this is from God, the hardship can act as a means for expiating previous sins and more importantly, this can raise the rank of the person in the hereafter.  

Who has created death and life, that He may test you which of you is best in deed. And He is the All-Mighty, the Oft-Forgiving.^[9]

Thus, because the hereafter is an everlasting realm, any suffering in this life is deemed to be insignificant. There are a number of texts reminding Muslims of the insignificance of this life and how and suffering in this life will ultimately be forgotten in the hereafter.

The Messenger of Allah (peace and blessings of Allah be upon him) said: “The most affluent of the people in this world, of those who will go to Hell, will be brought on the Day of Resurrection and dipped once in the Fire. Then it will be said: O son of Adam did you ever see anything good? Did you ever have any pleasure? He will say: No, by Allah, O Lord. Then the most destitute of the people in this world, of those who will enter Paradise, will be brought and dipped once in Paradise, and it will be said to him: O son of Adam, did you ever see anything bad? Did you ever experience any hardship? He will say: No, by Allah, O Lord. I never saw anything bad and I never experienced any hardship.”^[10]

Taking these texts into consideration of the context of the current discourse, one can deduce that Muslims believe in an Almighty Creator who has forbidden people to take their own lives regardless of the situation. Specifically in the case of assisted suicide, this cannot be justified on grounds of compassion and ease of suffering, as doing so equates to rejecting the test that God has placed upon a particular individual. As the Muslim’s ultimate vision is to seek the best abode in the hereafter where any worldly suffering will be forgotten, the encouragement is there to patiently endure any illness which can ultimately act as a source of expiation, thus raising the rank of the Muslim in the hereafter. Therefore, with the correct mindset, any apparent suffering experienced in this life may ultimately be a source of good for an individual.

The Need For Action

Despite the significant media attention surrounding the issue of assisted suicide, Muslims in general have been remarkably quiet on the issue. As Muslims, we must strive to call to that which is good and actively warn against things which go against what God has commanded, for doing so will ultimately harm humanity. For Muslims to sit back idly knowing that the potential exists for assisted suicide to become legal in the UK is simply unacceptable.

We can perhaps learn a number of lessons from the legalisation of abortion in the UK. Since the late 1960s abortion rates have continued to rise and we haven’t seen a sizeable reduction in the abortion rate since the mid 1970s. We must ask ourselves whether this really is a satisfactory outcome. Whether one agrees or disagrees with abortion, both sides of the debate should be united on the point that abortion rates must be kept to an absolute minimum. We must ask if we as society have really done enough to identify and effectively address the root causes of why people might end up seeking abortions. Moreover, although abortion has become widely accepted amongst the public, do people stop and ponder over the ethical and moral implications of their actions?

If assisted suicide was to be legalised in the UK, it would be worrying to observe a similar pattern of events as with the case of abortion, where we would initially see a sharp rise in cases, with a gradually increasing rate over the ensuing years. Would the people in the future really think deeply as we are now about the ethical implications of prematurely ending one’s life, or will it attain the status of ‘normality’ as abortion has? Perhaps they will be even less concerned in the prospect of going against the commandments of God either due to fewer people raising this point, or due to religions succumbing to pressure and eventually moving towards accepting the practice.  

It is for these reasons we must start becoming more vocal in this debate. Although there are a significant number of Muslim doctors in the UK, many of whom would describe themselves as orthodox, silence on this issue has been well and truly palpable. Muslim doctors must work in conjunction with Muslim scholars and thinkers to construct a sound argument against assisted suicide. In addition, they must collaborate with other groups who call against the motion, to give the overall movement more strength.

[1] BBC, Assisted Suicide, Strong Case For Legislation http://www.bbc.co.uk/news/health-16410118 Accessed 25/12/2012

[2] Simon Jenkins. Assisted Suicide, The Government must not visit indignity on the terminally ill.http://www.guardian.co.uk/commentisfree/2012/jan/05/assisted-dying-indignity-terminally-illAccessed 25/12/2012

[3]Andrew Warnock. Assisted Suicide is Never an Autonomous Choice.http://www.guardian.co.uk/commentisfree/andrewbrown/2012/jan/05/assisted-suicide-autonomous-choice. Accessed 25/1/2012

[4] British Medical Association,http://www.bma.org.uk/images/Euthanasia%20%26%20PVS%20-%20ARM%20discussion%20paper_tcm41-146697.pdf Accessed 25/1/2012

[5] Martin Beckford. Church of England calls Assisted Suicide Plan Morally Unacceptable.http://www.telegraph.co.uk/news/uknews/law-and-order/8994338/Church-of-England-calls-assisted-suicide-plan-morally-unacceptable.html Accessed 25/1/2012

[6] Quran 4:29

[7] Quran 6:151

[8] Bukhari Vol 4. Book 56, Hadith Number 669

[9] Quran 67:2

[10] Bukhari 6202

Zam Zam – Holy or Poisonous?

The BBC has recently highlighted concerns surrounding Zam Zam water that it is contaminated with harmful elements.[1] In an undercover investigation, they exposed the illegal selling of Zam Zam water in Islamic Bookshops and following analysis of the water being sold, they found high levels of nitrate and levels of arsenic three times above the maximum permitted level. Moreover, they asked an undercover pilgrim to retrieve some Zam Zam water from the source, and they found the composition of this water to be similar to that being sold in the UK. 

Despite performing such a covert ‘sting’ operation, maybe one should try to give the BBC the benefit of doubt. Perhaps the sole purpose of conducting such an investigation is that the BBC genuinely cares about the health and wellbeing of the British Muslim Community, as opposed to using Islam yet again as the journalist’s trump card to boost television ratings.

The investigation performed by the Beeb actually has far wider implications than merely protecting the health of British Muslims. Their findings suggest that the monitoring of Zam Zam water is either non-existant or wholly inadequate and that the research which is being done on the properties of Zam Zam is not robust in its nature. In addition, as Zam Zam water is consumed by Muslims worldwide, the statement made by the president of the Association of Public Analysts that he “certainly would not recommend drinking it” goes totally against the belief of Muslims. Whilst Muslims may have differences on a number of issues, the belief in the miraculous nature of Zam Zam is something that unites Muslims around the world. 

It is therefore paramount that if the Beeb is publicising such a high profile scientific argument that Zam Zam water is contaminated, the investigations should have been submitted for publication in a high impact journal in the relevant field. In doing so, their investigation would have gone through a robust peer review process, comparing their findings and methodology to existing literature in the field of investigation. The purpose of such a process is to ensure quality of scientific data, and eliminate all bias in scientific publications. Unfortunately the investigators have failed to follow this established protocol of entering into scientific debate on a matter. Based on this alone, one would have to conclude that the Beeb has been irresponsible in exposing the ‘contamination’ of Zam Zam on investigations which have not been peer-reviewed and thus potentially subject to bias.

The argument put forward by the BBC may be strengthened by the declaration from the Food Standards Agency that Zam Zam water being sold in the UK contains high levels of nitrate and arsenic. They further state that the risk posed to occasional drinking of the water by adults and older children would be very low.[2] However, such declerations do not seem to have been made by other similar agencies throughout the world. In fact Michael Herndon of the Food and Drug Authority in the United States made a statement in 2005 that the FDA has “..not heard any health alerts regarding Zam Zam water in US markets” and “If we thought there was a problem, we would alert the borders before the product enters the country”.[3]

Since then, the FDA has not made statements on its potential harmful effects. In addition, the World Health Organisation is yet to make a statement on the contamination of Zam Zam water. If the consumption of the water is a potential worldwide health concern, as depicted by the BBC, the fact that the WHO has totally neglected this implies that they have either demonstrated sheer incompetence, or that they do not feel there is sufficient evidence to make such claims. 

Whilst the BBC can be criticised for publicising scientific information which has neither been peer reviewed nor been validated by consensus amongst similar bodies around the world, it is important for the Muslim community not to react to such claims emotionally. There may well be some truth in what the BBC has unearthed, and it is therefore important to examine their claims through the lens of science.     

Scientific Strength?

Arsenic is a heavy metal which exists in organic and inorganic forms. It occurs naturally in bedrock, where it dissolves readily into ground water through weathering or volcanic eruptions. It may also enter the water system through anthropogenic processes such as mining activities, the use of pesticides and the burning of fossil fuels with high arsenic content. In such instances, arsenic may be transported through long distances as particles in air or water.[4][5] Long term arsenic exposure may lead to Arsenicosis, which is typified by skin problems, cancer (particularly urological cancers), and diseases of the blood vessels of the legs and feet[6]. 

Nitrate is the most frequently introduced pollutant into the groundwater system[7]. Nitrate contamination usually occurs from diffuse sources such as intensive agriculture and unsewered sanitation in densely populated regions or point sources such as irrigation of land by sewage effluent[8][9][10]. The adverse health effects of high nitrate levels are well known. It may be particularly dangerous to infants, by affecting the ability of blood to release oxygen to surrounding tissues (methaeglobinaemia).[11] Nitrates are also associated with Non-Hodgkins Lymphoma and colorectal cancer[12].

The World Health Organisation has published standards for drinking water, stating that levels of arsenic should not exceed 10 µg/l[13]  and nitrate should not exceed 50mg/l[14]. The maxmimum level for nitrate is based upon epidemiological studies in which methaeglobinaemia was not reported in infants in areas where drinking water contained less than 50mg of nitrate per litre. However, the WHO state that with regards to arsenic there remains ‘considerable uncertainty’ over the actual risks at low concentrations. They have also said that in many countries the guideline value may not be attainable, and if this is the case, then every effort must be made to keep concentrations as low as possible.

[15] Whilst it is quite clear that extremely high levels of arsenic in drinking water can be detrimental to health (as evident in endemic areas such as South America, Bangaldesh and Nepal), the effect of chronic low level exposure is not so clear. Therefore, the labelling of Zam Zam water as poisonous on account of its arsenic content (which would at most be 30µg/l if we are to take the BBCs investigation as evidence) is perhaps an over-confident statement when one considers that the body setting the standard itself is uncertain on the matter. 

The Saudi Geological Survery has a department dedicated to research on Zam Zam water.[16] It is however unfortunate that there has been very little contribution from this department to the scientific literature on the composition of Zam Zam water. Whilst the Saudi Geological Survey ought to be congratulated for their efforts in monitoring the water through the King Abdullah Zamzam Water Distribution Centre, it is a shame they cannot back their statements that the Holy Water is ‘not contaminated’ with valid scientific evidence

[17].  In fact, there generally is a paucity of high quality scientific analysis of Zam Zam water. As such, there is no ‘official’ statement on the exact composition of the water, and perhaps this information needs to be publicised given its mass consumption. Of the very few studies available, the analysis by Naeem et al[18] found levels of toxic elements including arsenic to be below the danger level of human consumption. However, the standard which they were testing against is unclear. A further study examined the level of nitrate in various parts of Saudi Arabia, and the found the average amount of nitrate in the wells of Mecca to be 41.8mg/l, with 21 out of 85 wells having nitrate levels above 45mg/l (which is 5mg/l less than the WHO limit)[19]. However, their studydoes not clarify whether they have included the Zam Zam well in their analysis. More recently, the Saudi Gazette reported that the King Fahad University for Petroleum and Mineral Resources perfomed tests on Zam Zam water using the latest technology and they concluded that the water is fit for human consumption[20]. However, perhaps the Saudi Gazette may be just as guilty as the BBC in reporting on an investigation which doesn’t seem to have been peer reviewed and published. 

Alongside the provision of such data, it would also be prudent to look at epidemiological data on the occurrence of arsenicosis and methaeglobinaemia in areas where Zam Zam is consumed in high volumes, namely Mecca and Medina. Whilst the occurrence of arsenicosis is well documented in Bangladesh and the Far East[21][22][23], there is no published epidemiological data on the occurrence of these conditions in the Arab peninsula and furthermore, there is no epidemiological study on the occurrence of methaeglobinaemia in the Arab peninsula, implying that there has either been gross underreporting of these conditions, or that they are extremely rare entities. Thus in the absence of such data from the areas where Zam Zam is consumed in large quantities, it is difficult to accept the hypothesis that Zam Zam water is poisonous.  

Conclusion

The BBC should have acted in a more responsible manner. The investigation into Zam Zam water should have been peer-reviewed by independant experts in the field and then be published in a reputable scientific journal before being given media attention. This is the general pattern that is followed when a clinical trial unravels a novel medication, or if a particuar medicine is deemed to be unsafe for consumption, and the BBC should have followed a similar protocol when publicising these findings. Perhaps the absence of a powerful drug company waiting to pounce on any hint of defamation gave the BBC some courage in publicising their findings. By presenting the results of their sting operation in such a fashion, one can only conclude that there principle motive was not to protect the health of British Muslims, but to create ‘good TV’ by playing the Islam card. In addition, academic institutions in Muslim countries, particularly the Saudi Geological Survey, should be encouraged to publicise their research on Zam Zam through scientific journals so that there is clarity on an issue which affects Muslims globally. Following scientific debate through publications and discussion at scientific meetings, should it emerge that there is robust evidence to prove that Zam Zam is poisonous to drink; the custodians of the Well should take the responsibility to ensure that the water is safe for human consumption.   

 [1] British Broadcasting Corporation http://www.bbc.co.uk/news/uk-england-london-13267205).viewed on 19/5/2011

[2] Food Standards Agency http://www.food.gov.uk/news/newsarchive/2010/jul/zamzam viewed on 19/5/2011

[3]Muslim Link Paper http://www.muslimlinkpaper.com/index.php/community-news/community-news/266-No%20Arsenic%20in%20American%20Zam%20Zam%20Water.html viewed on 19/5/2011

[4] J.C. Ng, J. Wang and A. Shraim, A global health problem caused by arsenic from natural sources, Chemosphere 52 (2003), pp. 1353–1359

[5] S. Wang and C.N. Mulligan, Arsenic mobilization from mine tailings in the presence of a biosurfactant, Applied Geochemistry 24 (2009), pp. 928–935

[6]World Health Organisation http://www.who.int/water_sanitation_health/diseases/arsenicosis/en/viewed on 19/5/2011

[7] Spalding, R. F., & Exner, M. E. (1993). Occurrence of nitrate in groundwater—a review. Journal of Environmental Quality, 22, 392–402

[8] Keeney, D. (1986). Sources of nitrate to groundwater. CriticalReviews in Environmental Control, 16, 257–304.

[9] Bouchard, D. C., Williams, M. K., & Surampalli, R. Y. (1992). Nitrate combination of groundwater sources and potential health effects. Journal of the American Medical Association, 7, 85–90.

[10] Eckhardt, D. A. V., & Stackelberg, P. E. (1995). Relation of groundwater quality to land use on Long Island, New York. Groundwater, 33, 1019–1033.

[11] Fan, A. M., Willhite, C. C., & Book, S. A. (1987). Evaluation of the nitrate drinking water standard with reference to infant methemoglobinemia and potential reproductive toxicity. Regulatory Toxicology and Pharmacology, 7, 135–148

[12] Gulis, G., Czompolyova, M., & Cerhan, J. R. (2002). An ecological study of nitrate in municipal drinking water and cancer incidence in Trnava district, Slovakia. Environmental Research, 88, 182–187.

[13] World Health Organisation. Guidlines For Drinking Water Quality 3^rd edition, incorporating the first and second addenda. Vol IGeneva 2008, p306

[14] World Health Organisation. Guidlines For Drinking Water Quality 3^rd edition, incorporating the first and second addenda. Vol IGeneva 2008, p417

[15] World Health Organisation. Guidlines For Drinking Water Quality 3^rd edition, incorporating the first and second addenda. Vol IGeneva 2008, p307

[16] Saudi Geological Survey http://www.sgs.org.sa/English/earth/Pages/Zamzam.aspx viewed on 19/5/2011

[17] Arab News http://arabnews.com/saudiarabia/article386684.ece Viewed on 19/5/2011

[18] Naeem, A, Alsanussi, MY, Almohandis, AA. Multielemental and Hydrochemical Study of Holy Zamzam Water. Journal of the New England Water Works Association Vol. 97, No. 2, p 158-169, June, 1983

[19]Abdulrahman I. Alabdula’aly, Abdullah M. Al-Rehaili, Abdullah I. Al-Zarah, Mujahid A. Khan. Assessment of nitrate concentration in groundwater

in Saudi Arabia. Environ Monit Assess (2010) 161:1–9

[20]Saudi Gazette http://www.saudigazette.com.sa/index.cfm?method=home.regcon&contentID=20110511100412 viewed on 19/5/2011

The Puff Culture. Is it really harmful?

Introduction

Over the course of the last decade, there has been a remarkable surge in the prevalence of shisha smoking, particularly amongst the younger generation. This popularity has been fuelled in part by the appeal of inhaling flavoursome smoke alongside the emergence of numerous exotically decorated ‘shisha cafes’, where one can indulge in a myriad of tobacco flavours ranging from fruity apple to fizzy coca-cola. Perhaps the most significant factor in the rise of shisha smoking lies in the belief which many people hold, that it is a ‘healthier’ or ‘herbal’ alternative to cigarettes as it doesn’t have carcinogenic effects. In addition, many believe that shisha smoking doesn’t lead to addiction and as a result may be helpful to those who wish to give up smoking cigarettes.

Muslim scholars are unanimous in their position that smoking is something which is highly discouraged in Islam. Their principle reason for passing such a ruling is the well known adverse effects to one’s health which smoking causes. Food and drink (which includes smoking) may sub-classified into two categories; things which are good and bring benefit or things which are bad and bring harm.

“He allows them as lawful al-tayyibaat (i.e. all good and lawful things eg. deeds, beliefs, persons and foods), and prohibits them as unlawful al-khabaa’ith (i.e. all evil and unlawful things eg. deeds, beliefs, persons and foods)”^[1]

Based on this verse from the Quran, scholars have regarded the act of smoking to fall under the label of Khabaa’ith or evil things, as opposed to something virtuous.  Further strength to their argument is added by the amount of money which a smoker wastes on buying something which brings about no benefit and the bad smell which a smoker frequently has causing harm to those around him.

Despite the agreement amongst Islamic scholars that smoking is something highly discouraged, shisha smoking continues to gain popularity amongst the Muslim youth. A few reasons for this may include a lack of awareness amongst some members of the youth on the shar’i (legal) evidences against smoking, or perhaps they are aware of the evidence but are indifferent towards it. Whilst this section of the Muslim youth continues to smoke shisha in ignorance, a second group are well aware of the evidence against smoking but contest it, citing their belief that shisha smoking cannot be grouped with other types of smoking as it isn’t associated with the adverse health issues, and furthermore, it smells nice. Moreover, if the shisha is bringing people together to share and benefit from each other’s company, then surely that can be described as money well spent?

The purpose of this article is to examine the scientific evidence on the issue of shisha smoking and to ascertain whether the beliefs of shisha smokers are indeed valid, or if their ‘beliefs’ should be relabelled ‘myths’.

A Global Issue

Shisha smoking continues to gain popularity throughout the Muslim world. A study which examined smoking habits in 16 countries in the Eastern Mediterranean region including the Gaza Strip reported that regular Shisha smoking ranges from 6% to 34% amongst 13-15 year olds.[2] Azab and colleagues[3] have also demonstrated a staggering 42.7% prevalence of regular Shisha smoking amongst a sample of 548 Jordanian university students. The perception of shisha smoking being less harmful than smoking cigarettes is highlighted by studies of medical students in the Middle East, which showed a prevalence of 20% amongst Lebanese students, 23.5% amongst Syrian students[4], and 28.6% amongst Turkish[5] students.[6]

The appeal of shisha smoking isn’t confined to eastern Muslim countries alone. A study conducted amongst more than 900 British university students found that 38% had smoked shisha.[7] A much larger study in the US looked at shisha usage among a sample of 8745 students which demonstrated that almost 30% had smoked shisha.[8] However, perhaps the strongest evidence demonstrating the growth of shisha smoking comes from the Global Youth Tobacco Survey, which looked at trends in tobacco usage among more than half a million youths aged between 13-15 worldwide during a ten year period. The results showed that whilst cigarette use seems to be either stabilised or declining, usage of other forms of tobacco, notably shisha smoking, are on the rise.5

Is it Really Harmful?

A recent systematic review looking at a number of studies trying to answer this question found that shisha smoking more than doubles the risk of developing lung cancer, respiratory illnesses such as Chronic Obstructive Pulmonary Disease (COPD), and for pregnant women, low birth weight babies. The review also suggests that a relationship between shisha smoking and other types of cancer cannot be excluded.[9] A further systematic review concluded that shisha smoking had a similar effect on worsening lung function as cigarette smoking does which agrees with the aforementioned study that shisha smoking increases the risk of developing COPD.[10]

There have also been a few studies which have compared the composition of shisha smoke with that of cigarette smoke. In fact, shisha smoke contains high levels of compounds such as carbon monoxide, polyaromatic hydrocarbons (which are associated with lung cancer) and nicotine.[11][12][13]

During the average smoking session, a shisha smoker can inhale on average 119L of smoke, which contains 150 milligrams of carbon monoxide, 4 milligrams of nicotine and 602 milligrams of ‘tar’.[14]This is an interesting finding, particularly as many shisha smokers relay the claim made on shisha tobacco packets that it contains ‘0% tar’. It has also been suggested that during a shisha smoking session, the smoker is subject to 3-9 times the level of carbon monoxide when compared to a single cigarette.[15] Taking this information into account may help to explain the recent reports in scientific literature concerning smokers being taken to the Accident and Emergency department with acute carbon monoxide poisoning secondary to shisha smoking, something which has never been reported with cigarette usage.[16][17]

Is Shisha Smoking Addictive?

Whilst the addictive effects of nicotine are well known, many believe that the amount of nicotine they are exposed to whilst smoking shisha is much less than that of a cigarette, and therefore the addictive effects of nicotine in shisha tobacco are not clearly obvious. A study by Neergard corrects this misconception by concluding that the nicotine exposure from one session of shisha smoking is equivalent to smoking 10 cigarettes a day.[18] Furthermore, shisha smokers may begin to exhibit traits of dependence, such as drug-seeking behaviour, escalation of use with time and an inability to quit despite repeated attempts.[19] In a random sample of 268 shisha smokers in Syria, 28% of respondents said they wished to stop smoking, and 59% said they had tried stopping but were unsuccessful in doing so.[20]

The Syrian Centre for Tobacco Studies postulates that there are two facets to the addiction which shisha smoker’s exhibit. The first is associated with nicotine, whilst the second reflects the social dimension around shisha smoking, with the more dependant smokers showing solitary and home-based smoking patterns.

A further study conducted amongst 762 Danish youths has proved that shisha smokers are more likely to progress to regular cigarette smoking. This piece of evidence not only adds strength to the argument that shisha smoking can lead to addiction, but also dispels the myth that shisha smoking can be used as an aid to help quitting cigarette smoking.[21] Based on the Islamic principle of staying away from things that lead to harm, even if one were to believe that shisha smoking is less harmful than cigarette smoking, the fact that it has been proven to lead to cigarette smoking adds strength to the scholarly position of shisha smoking being something in opposition to the core principles of Islam.

Fear of the Unknown

Perhaps the greatest danger with shisha smoking is the fact that there are many unknowns and variables in analysing its true effect on human health. The shisha market does not have the same type of regulation as other branches of the tobacco industry, and as a result, there is no standardisation in the content or packaging of shisha tobacco and other accessories. Perhaps this might explain why claims of ‘0% tar’ go unnoticed, especially when scientific evidence shows us otherwise. In addition, given the huge variety of shisha tobaccos and various grades of charcoal, it is very difficult to determine exactly what the shisha smoker is inhaling. Indeed, one study unearthed that one of the brands of charcoal frequently used by shisha smokers already contained high levels of polyaromatic hydrocarbons which are strongly associated with lung cancer.[22] The synergistic effect of this along with the toxic chemicals from the tobacco (as shown above) could potentially have devastating effects on one’s health in the long term.

Conclusions

Contrary to popular belief there is plenty of evidence within scientific literature to suggest that shisha smoking maybe as equally harmful as cigarettes, and in some instances even more harmful. There is a strong association between shisha smoking and lung diseases such as COPD and lung cancer, with a possibility of other forms of cancer also being associated with this form of smoking. In addition, shisha smokers are exposed to high levels of toxic substances during a smoking session, many of which exceed the amount of toxins found in a single cigarette. The fact that shisha smoking has been known to cause acute carbon monoxide poisoning requiring hospital admission must be duly noted, particularly as this is not a phenomenon common with cigarette smoking.

The information presented in this brief review is of particular relevance to healthcare professionals who should educate their patients on the dangers of shisha smoking with scientific evidence. Furthermore, it would be prudent for the scholars of Islam, namely Islamic jurists, to take this evidence based information on board when considering religious rulings pertaining to shisha smoking.

[1] Sural Al-A’raf 7:157

[2] Warren, C. W., Lea, V., Lee, J., Jones, N. R., Asma, S., & McKenna, M. (2009). Change in tobacco use among 13–15 year olds between 1999 and 2008: Findings from the Global Youth Tobacco Survey. Global Health Promotion, 16(2_suppl), 38−90.

[3] Azab, M., Khabour, O. F., Alkaraki, A. K., Eissenberg, T., Alzoubi, K. H., & Primack, B. A. (2010). Water pipe tobacco smoking among university students in Jordan. Nicotine & Tobacco Research, 12(6), 606−612

[4] Almerie, M., Matar, H., Salam, M., Morad, A., Abdelal, M., & Maziak, W. (2008). Cigarettes & waterpipe smoking among medical students in Syria: A cross-sectional study. The International Journal of Tuberculosis and Lung Disease, 12(9), 1085−1091

[5] Poyrazoğlu, S., Şarli, Ş., Gencer, Z., & Günay, O. (2010). Waterpipe (narghile) smoking among medical and non-medical university students in Turkey. Upsala Journal of Medical Sciences, 115(3), 210−216.

[6] Saade, G., Warren, C., Jones, N., & Mokdad, A. (2009). Tobacco use and cessation counseling among health professional students: Lebanon Global Health Professions

Student Survey. Le Journal Médical Libanais, 57(4), 243−247.

[7] Jackson, D., & Aveyard, P. (2008). Waterpipe smoking in students: Prevalence, risk factors, symptoms of addiction, and smoke intake. Evidence from one British university. BMC Public Health, 8, 174.

[8] Primack, B., Fertman, C., Rice, K., Adachi-Mejia, A., & Fine, M. (2010). Waterpipe and cigarette smoking among college athletes in the United States. The Journal of

Adolescent Health, 46(1), 45−51.

[9] Akl, E. A., Gaddam, S., Gunukula, S. K., Honeine, R., Jaoude, P. A., & Irani, J. (2010). The effects of waterpipe tobacco smoking on health outcomes: A systematic review. International Journal of Epidemiology, 39(3), 834−857.

[10] Raad, D., Gaddam, S., Schunemann, H. J., Irani, J., Abou Jaoude, P., Honeine, R., et al. (2010). Effects of waterpipe tobacco smoking on lung function: A systematic

review and meta-analysis.Chest Jul 29. [Epub ahead of print].

[11] Maziak, W. (2010). The waterpipe—A global epidemic or a passing fad. International Journal of Epidemiology, 39(3), 857−859.

[12] Shihadeh, A., & Saleh, R. (2005). Polycyclic aromatic hydrocarbons, carbon monoxide, “tar”, and nicotine in the mainstream smoke aerosol of the narghile water pipe. Food and Chemical Toxicology, 43(5), 655−661.

[13] Shihadeh, A. (2003). Investigation of mainstream smoke aerosol of the argileh waterpipe. Food and Chemical Toxicology, 41(1), 143−152

[14] Katurji M, Daher N, Sheheitli H, Saleh R, & Shihadeh A, (in press.). Direct measurement of toxicants inhaled by waterpipe users in the natural environment using a realtime in-situ smoke sampling (RINS) technique. Inhalation Toxicology

[15] Eissenberg, T., & Shihadeh, A. (2009). Waterpipe tobacco and cigarette smoking: Direct comparison of toxicant exposure. American Journal of Preventive Medicine, 37(6), 518−523.

[16] Lim, B., Lim, G., & Seow, E. (2009). Case of carbon monoxide poisoning after smoking shisha. International Journal of Emergency Medicine, 2(2), 121−122.

[17] Uyanık, B., Arslan, E., Akay, H., Erçelik, E.,& Tez,M. (2009). Narghile (Hookah)smoking and carboxyhemoglobin levels. The Journal of Emergency Medicine Epub ahead of print].

[18] Neergaard, J. S. P., Job, J., & Montgomery, S. (2007). Waterpipe smoking and nicotine exposure: A review of the current evidence. Nicotine & Tobacco Research, 9(10), 987−994.

[19] Maziak, W., Eissenberg, T., & Ward, K. D. (2005). Patterns of waterpipe use and dependence: Implications for intervention development. Pharmacology Biochemistry and Behavior, 80(1), 173−179

[20] Ward, K., Hammal, F., VanderWeg, M., Eissenberg, T., Asfar, T., Rastam, S., et al. (2005). Are waterpipe users interested in quitting? Nicotine & Tobacco Research, 7, 149−156

[21] Jensen, P., Cortes, R., Engholm, G., Kremers, S., & Gislum, M. (2010). Waterpipe use predicts progression to regular cigarette smoking among Danish youth. Substance

Use & Misuse, 45(7–8), 1245−1261

[22] Sepetdjian, E., Saliba, N., & Shihadeh, A. (2010). Carcinogenic PAH in waterpipe charcoal products. Food and Chemical Toxicology (Electronic publication ahead of print).