Prohibition of Qat (Khat) Chewing and Tobacco Smoking Does Not Work. Harm Reduction and Consistent Drug Education Do
Kamal Chaouachi, Tobacco researcher and consultant (Paris)
25 June 2009
Thanks to the Harm Reduction Journal for publishing this very interesting article on Qat (Khat) by Dr Hussein Ageely [1]. The reader may regret however that the author have not sufficiently underscored the importance of the sociologic and anthropologic context of Qat (Khat) use. For instance, 10 years ago, a retired professor of chemical pathology concluded the narration of his own participating experience in a Qat party with these words:
“Every society has its own forms of chemical escape”[2].
Also, unlike most authors, Dr Ageely did not apparently deem relevant to mention the co-occuring use of one of the different local water pipes during the Qat parties. This tall pipe is called Mada'a (whereas it is named Argeely in Lebanon, Palestine, Syria and Jordan). The Mada’a is used with plain tobacco -and perhaps now the mellow Shisha, a newcomer to Yemen, with its numerous and powerful flavours – is indeed a key element during the long ritual Qat parties of each afternoon [3].
Medical anthropologists have rebutted most of the allegations regarding the direct effects of Qat use on health by Western visitors to Yemen. They concluded that while “[Qat] cannot be completely discounted as a health threat, yet […] the majority view of the Yemenis is most plausible, particularly since most of the people are moderate or light users: the most harmful effects of Qat are probably in the realm of economics rather than in the realm of health"[4].
Drug education is undoubtedly very important and Dr Ageely is right to suggest awareness raising among students through television and religious programmes [1]. However, the “prohibition of cultivation of khat” and the “destruction of khat trees and ban imports of khat from Yemen” might be steps that would jeopardise the social cohesion of an entire region already affected by more serious problems.
Consequently, instead of considering prohibition as the unique alternative, why not contemplate and put forward harm reduction techniques just as those emerging in the field of tobacco smoking ? Indeed, the prohibition of drugs, and tobacco in particular, has never worked [5], does not work and coercion often ends up in human and public health catastrophes [5][6[7]. A long series of articles in the Harm Reduction Journal shows this.
A good example is smokeless tobacco of the Swedish SNUS type. Indeed, tobacco chewing is particularly hazardous if one uses low quality products such as those widely available in Asia and Africa. Dr Ageely probably knows a similar product called Shamma in the Middle East. However, comparative studies on smokeless tobaccos have shown that SNUS is much more safer [8].
Millions of lives could be saved in these parts of the world and a recent study published in the Harm Reduction Journal suggested that it could be an alternative to heavy hookah smokers [9]. However, smokeless tobacco of the Swedish SNUS type has a universal ambition and can be an efficient alternative to tobacco smoking among US-Americans as well [10].
Consequently, why not envisage for Qat users who do not want to quit a small bag -of, either concentrated qat juice or raw leaves- that they would place inside their mouth just as SNUS tobacco users do ? Within such a conceptual framework, the promotion of such a harm reduction alternative should normally be the mission of an agency like the WHO (World Health Organisation). Unfortunately, for its experts, all smokeless products are “deadly” [9].
Against this gloomy background, and instead of blindly importing from the West public health and prevention models more or less based on prohibition, a more socially and culturally adapted policy could be implemented. It would rely on the local creativity of local scientists in Asia and Africa, who, for the great majority of them, have been working independently from the direct or indirect influence of pharmaceutical companies and other transnational interests. Furthermore, from a geopolitical and health viewpoint, the Qat issue is amazingly similar to that of the coca leaf, isn’t it ? United Nations bodies and agencies such as the INCB (International Narcotics Control Board) or the WHO, are known to have erred more than once and produced and disseminated highly controversial recommendations and reports [11][12][13][14].
Dr Ageely is kindly invited to forward this proposal to the officials of the Kingdom of Saudi Arabia and its scientific community.
Kamal Chaouachi
__________________
REFERENCES:
[1] Ageely HM. Prevalence of khat chewing in students of Jazan region. Harm Reduct J 2009, 6:11 (20 June 2009)
[2] Baron DN, The qat party. BMJ. 1999 Aug 21;319(7208):500.
[3] Chaouachi K. Qat chewing and water pipe (mada'a) smoking in Yemen: a necessary clarification when studying health effects on oral mucosa. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2007; 104: 731-733.
[4] Kennedy JG, Teague J, Rokaw W, Cooney E. A medical evaluation of the use of qat in North Yemen. Soc Sci Med. 1983;17(12):783-93.
[5] Marks J. Drug Misuse and Social Cost. Br J Hosp Med. 1994 Jul 13-Aug 16;52(2-3):65, 67.
[6] Snowdon C: Velvet Glove, Iron Fist. United Kingdom, Little Dice, 2009, 415 pages.
http://www.velvetgloveironfist.com/
[7] Chaouachi K. Harm reduction techniques for hookah (shisha, narghile, “water pipe”) smoking of tobacco based products. Medical Hypotheses 2009 [in press]
[8] Ibrahim SO, Vasstrand EN, Johannessen AC, Lillehaug JR, Magnusson B, Wallström M, Hirsch JM, Nilsen R: The Swedish snus and the Sudanese toombak: are they different? Oral Oncol. 1998 Nov;34(6):558-566.
[9] Sajid KM, Chaouachi K, Mahmood R. Hookah smoking and cancer. Carcinoembryonic Antigen (CEA) levels in exclusive/ever hookah smokers. Harm Reduct J 2008 24 May;5(19)
[10] Rodu B, Phillips CV. Harm Reduct J. 2008 May 23;5:18. Switching to smokeless tobacco as a smoking cessation method: evidence from the 2000 National Health Interview Survey.
[11] Oxman AD, Lavis JN, Fretheim A. Use of evidence in WHO recommendations. Lancet. 2007 Jun 2;369(9576):1883-9.
[12] Chaouachi K. A Critique of the WHO's TobReg "Advisory Note" entitled: "Waterpipe Tobacco Smoking: Health Effects, Research Needs and Recommended Actions by Regulators. Journal of Negative Results in Biomedicine 2006 (17 Nov); 5:17.
http://www.jnrbm.com/content/5/1/17
[13] Small D, Drucker E. Return to galileo? The inquisition of the international narcotic control board. Harm Reduct J. 2008 May 7;5:16.
[14] Chaouachi K. The Lessons of May, 58th. How We Tried to Change the World at the 58th Session of the United Nations INCB (International Narcotics Control Board) - Vienna, 9 May 1995 [a comment on above reference]
I have no competing interests. I have never received financial or non-financial, direct or indirect, funding neither from pharmaceutical companies (nicotine ‘‘replacement’’ therapies and products) nor from the tobacco industry.
Harm Reduction Journal
Prohibition of Qat (Khat) Chewing and Tobacco Smoking Does Not Work. Harm Reduction and Consistent Drug Education Do
25 June 2009
Thanks to the Harm Reduction Journal for publishing this very interesting article on Qat (Khat) by Dr Hussein Ageely [1]. The reader may regret however that the author have not sufficiently underscored the importance of the sociologic and anthropologic context of Qat (Khat) use. For instance, 10 years ago, a retired professor of chemical pathology concluded the narration of his own participating experience in a Qat party with these words:
“Every society has its own forms of chemical escape”[2].
Also, unlike most authors, Dr Ageely did not apparently deem relevant to mention the co-occuring use of one of the different local water pipes during the Qat parties. This tall pipe is called Mada'a (whereas it is named Argeely in Lebanon, Palestine, Syria and Jordan). The Mada’a is used with plain tobacco -and perhaps now the mellow Shisha, a newcomer to Yemen, with its numerous and powerful flavours – is indeed a key element during the long ritual Qat parties of each afternoon [3].
Medical anthropologists have rebutted most of the allegations regarding the direct effects of Qat use on health by Western visitors to Yemen. They concluded that while “[Qat] cannot be completely discounted as a health threat, yet […] the majority view of the Yemenis is most plausible, particularly since most of the people are moderate or light users: the most harmful effects of Qat are probably in the realm of economics rather than in the realm of health"[4].
Drug education is undoubtedly very important and Dr Ageely is right to suggest awareness raising among students through television and religious programmes [1]. However, the “prohibition of cultivation of khat” and the “destruction of khat trees and ban imports of khat from Yemen” might be steps that would jeopardise the social cohesion of an entire region already affected by more serious problems.
Consequently, instead of considering prohibition as the unique alternative, why not contemplate and put forward harm reduction techniques just as those emerging in the field of tobacco smoking ? Indeed, the prohibition of drugs, and tobacco in particular, has never worked [5], does not work and coercion often ends up in human and public health catastrophes [5][6[7]. A long series of articles in the Harm Reduction Journal shows this.
A good example is smokeless tobacco of the Swedish SNUS type. Indeed, tobacco chewing is particularly hazardous if one uses low quality products such as those widely available in Asia and Africa. Dr Ageely probably knows a similar product called Shamma in the Middle East. However, comparative studies on smokeless tobaccos have shown that SNUS is much more safer [8].
Millions of lives could be saved in these parts of the world and a recent study published in the Harm Reduction Journal suggested that it could be an alternative to heavy hookah smokers [9]. However, smokeless tobacco of the Swedish SNUS type has a universal ambition and can be an efficient alternative to tobacco smoking among US-Americans as well [10].
Consequently, why not envisage for Qat users who do not want to quit a small bag -of, either concentrated qat juice or raw leaves- that they would place inside their mouth just as SNUS tobacco users do ? Within such a conceptual framework, the promotion of such a harm reduction alternative should normally be the mission of an agency like the WHO (World Health Organisation). Unfortunately, for its experts, all smokeless products are “deadly” [9].
Against this gloomy background, and instead of blindly importing from the West public health and prevention models more or less based on prohibition, a more socially and culturally adapted policy could be implemented. It would rely on the local creativity of local scientists in Asia and Africa, who, for the great majority of them, have been working independently from the direct or indirect influence of pharmaceutical companies and other transnational interests. Furthermore, from a geopolitical and health viewpoint, the Qat issue is amazingly similar to that of the coca leaf, isn’t it ? United Nations bodies and agencies such as the INCB (International Narcotics Control Board) or the WHO, are known to have erred more than once and produced and disseminated highly controversial recommendations and reports [11][12][13][14].
Dr Ageely is kindly invited to forward this proposal to the officials of the Kingdom of Saudi Arabia and its scientific community.
Kamal Chaouachi
__________________
REFERENCES:
[1] Ageely HM. Prevalence of khat chewing in students of Jazan region. Harm Reduct J 2009, 6:11 (20 June 2009)
http://www.harmreductionjournal.com/content/6/1/11
[2] Baron DN, The qat party. BMJ. 1999 Aug 21;319(7208):500.
[3] Chaouachi K. Qat chewing and water pipe (mada'a) smoking in Yemen: a necessary clarification when studying health effects on oral mucosa. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2007; 104: 731-733.
[4] Kennedy JG, Teague J, Rokaw W, Cooney E. A medical evaluation of the use of qat in North Yemen. Soc Sci Med. 1983;17(12):783-93.
[5] Marks J. Drug Misuse and Social Cost. Br J Hosp Med. 1994 Jul 13-Aug 16;52(2-3):65, 67.
[6] Snowdon C: Velvet Glove, Iron Fist. United Kingdom, Little Dice, 2009, 415 pages.
http://www.velvetgloveironfist.com/
[7] Chaouachi K. Harm reduction techniques for hookah (shisha, narghile, “water pipe”) smoking of tobacco based products. Medical Hypotheses 2009 [in press]
[8] Ibrahim SO, Vasstrand EN, Johannessen AC, Lillehaug JR, Magnusson B, Wallström M, Hirsch JM, Nilsen R: The Swedish snus and the Sudanese toombak: are they different? Oral Oncol. 1998 Nov;34(6):558-566.
[9] Sajid KM, Chaouachi K, Mahmood R. Hookah smoking and cancer. Carcinoembryonic Antigen (CEA) levels in exclusive/ever hookah smokers. Harm Reduct J 2008 24 May;5(19)
http://www.harmreductionjournal.com/content/5/1/19
[10] Rodu B, Phillips CV. Harm Reduct J. 2008 May 23;5:18. Switching to smokeless tobacco as a smoking cessation method: evidence from the 2000 National Health Interview Survey.
http://www.harmreductionjournal.com/content/5/1/18
[11] Oxman AD, Lavis JN, Fretheim A. Use of evidence in WHO recommendations. Lancet. 2007 Jun 2;369(9576):1883-9.
[12] Chaouachi K. A Critique of the WHO's TobReg "Advisory Note" entitled: "Waterpipe Tobacco Smoking: Health Effects, Research Needs and Recommended Actions by Regulators. Journal of Negative Results in Biomedicine 2006 (17 Nov); 5:17.
http://www.jnrbm.com/content/5/1/17
[13] Small D, Drucker E. Return to galileo? The inquisition of the international narcotic control board. Harm Reduct J. 2008 May 7;5:16.
http://www.harmreductionjournal.com/content/5/1/16
[14] Chaouachi K. The Lessons of May, 58th. How We Tried to Change the World at the 58th Session of the United Nations INCB (International Narcotics Control Board) - Vienna, 9 May 1995 [a comment on above reference]
http://www.harmreductionjournal.com/content/5/1/16/comments
Competing interests
I have no competing interests. I have never received financial or non-financial, direct or indirect, funding neither from pharmaceutical companies (nicotine ‘‘replacement’’ therapies and products) nor from the tobacco industry.
For more details, see the relevant section of: Chaouachi (2009) in: Int. J. Environ. Res. Public Health; 6(2):798-843).
http://www.pubmedcentral.nih.gov/articlerender.fcgi?tool=pubmed&pubmedid=19440416