The tobacco-free fallacy: What paediatricians should know about herbal smoking products

Abstract

While e-cigarette and combustible cigarette use remains more common among youth, herbal smoking products are gaining interest and popularity among children and adolescents. Herbal smoking products are often touted as a safer alternative to tobacco smoking or nicotine vaping; however, research suggests that they emit significant levels of toxicants and carcinogens posing risks to child and adolescent health. The low perceived risk coupled with youth-friendly flavours and easy access may entice youth to use herbal smoking products and increase the risk of subsequent tobacco and substance use. We discuss what is known about the use, health effects, and regulations of herbal smoking products and present strategies for policymakers and paediatric providers to reduce the risks associated with these products for Canadian youth.

Though e-cigarette use has now largely surpassed cigarette smoking among Canadian youth, a significant proportion continue to use combustible tobacco products. In addition to traditional tobacco-containing products, such as cigarettes and cigars, the use of herbal smoking products, such as herbal cigarettes and herbal shisha—the health risks of which remain largely unknown—is common among youth. The recent growth of the global wellness industry, currently valued at $4.4 trillion (1) may forecast a resurgence for these products.

DEFINITIONS

Herbal smoking products represent a wide range of products including herbal cigarettes, Asian herbal cigarettes, herbal hookah, bidis, and cloves (Table 1). While some herbal smoking products contain tobacco, the focus of this commentary is on combustible non-tobacco smoking products (i.e., herbal cigarettes and herbal shisha).

Table 1.

Herbal smoking products

Products	Description	Comments
Tobacco-free herbal smoking products
Herbal cigarettes	Cigarettes that do not contain tobacco or nicotine. Consists of a mixture of herbs and/or plant material including rose petals, raspberry leaves, chamomile, mullein, lavender, blue lotus, peppermint, mugwort, etc. (2).	Deliver similar amounts of toxic chemicals as those found in tobacco smoke (3).
Herbal shisha	Tobacco and nicotine free sugarcane-based molasses (i.e., tobacco-free shisha) infused with flavourings smoked by heating charcoal using a waterpipe device (4).	Contains harmful toxicants and carcinogens. Can be smoked in waterpipe cafés in certain Canadian provinces (4).
Tobacco-containing herbal smoking products
Tobacco shisha	Combination of tobacco and flavourings bound together with molasses or honey, smoked using a waterpipe device. Comes in a variety of flavours such as apple, strawberry, apricot, grape, bubble gum, etc. (2,4).	Originates from the Middle East and South Asia. Contains several harmful toxicants and carcinogens (4).
Bidis	Hand-rolled, unfiltered tobacco cigarettes wrapped in tendu leaves. Can be infused with sweet flavours (chocolate, vanilla, mango) (2).	Higher nicotine content than conventional tobacco cigarettes. Associated with increased risk of cancer and heart disease (5).
Clove cigarettes (Kreteks)	Made up of a blend of tobacco and cloves (2).	Increased risk for lung injury and abnormal lung function (5).
Asian herbal cigarettes	Cigarettes that are made up of a blend of traditional Asian medicinal herb extracts and tobacco leaves sold in many parts of Eastern and South-East Asia (6).	Marketed as a safer alternative to tobacco cigarettes by the Asian tobacco industry. Health claims include relieving respiratory symptoms, reducing toxins and organ protection; however, there is no evidence to support these claims (6).

Herbal smoking products are often advertised as a safer alternative to traditional tobacco products and are available in a wide variety of flavours. Herbal cigarettes are nicotine and tobacco-free cigarettes containing a mixture of plant material and herbs. Herbal shisha is a sugarcane-based nicotine-free product infused with flavourings and smoked using a hookah device (water pipe heated with charcoal).

EPIDEMIOLOGY

Recent prevalence data on herbal cigarette use in North America are limited. A survey conducted in the USA in 2002 among young adult users of non-traditional smoking products found that 34% had already tried herbal cigarettes and that use occurred mostly in social outings or when conventional cigarettes were not available (2). Of particular concern is evidence on social media revealing that herbal cigarettes are gaining popularity among youth (7).

Overall, 6.9% of 7th to 12th graders in Canada reported having ever used a hookah (herbal or tobacco) in 2018 to 2019 and use was highest among 10th to 12th graders with 10.9% reporting lifetime use (8). Data related to racial and ethnic background suggest higher rates of hookah use among youth of Middle Eastern descent (4,9). In 2013 to 2014, data from the COMPASS cohort study indicated that 4.3% of Ontario and Alberta youth reported having smoked herbal shisha in the past 30 days, whereas 2.2% reported past 30-day use of tobacco hookah (10). Preference for nicotine-free hookah products has also been reported among young adults (11), suggesting that youth may opt for nicotine and tobacco-free (herbal) products when available.

HEALTH RISKS

Herbal cigarette smoke delivers similar amounts of carbon monoxide (CO) and tar as tobacco cigarettes (3). Herbal cigarette smoke also contains significant levels of harmful toxicants such as benzo(a)pyrene, phenolic contents, and aromatic amines (3). As a result, cells exposed to tobacco and nicotine-free cigarettes tend to develop similar carcinogenic lesions as those exposed to tobacco cigarettes (12).

Herbal hookah smoke yields harmful toxicants in levels equivalent or exceeding tobacco-based hookah namely: CO, nitric oxide, volatile aldehydes, carcinogenic polycyclic aromatic hydrocarbons, and traces of heavy metals such as nickel, lead, chromium, and arsenic (13,14). Significant tar levels have been identified despite ‘0% tar’ labeling on the packaging of many herbal hookah products (13). A single hookah session reportedly lasts 20 to 80 minutes where users can inhale over 100 times the amount of smoke generated by a single cigarette, thus exposing users to large amounts of toxicants over a prolonged period (15). Hence, the risk profile of herbal hookah is in many ways comparable to tobacco hookah given their similar toxicant profile, and both pose an increased risk for the development of pulmonary diseases (16).

Finally, while herbal cigarettes and hookahs technically do not contain nicotine, their use may still lead to an oral fixation or a behavioural addiction to smoking. This may increase the risk of experimenting with tobacco and other psychoactive substances (17).

PUBLIC PERCEPTIONS

Herbal cigarettes are often viewed as a healthier alternative to cigarettes, particularly among ‘health-conscious’ consumers (7). Many false and misleading health claims regarding the ‘benefits’ of herbal cigarettes circulate on social media platforms, notably: the relief of anxiety, acne, menstrual cramps, and insomnia, potentially influencing youth to try these products (7).

As a brief proof-of-concept experiment, we searched the TikTok, Instagram and Reddit platforms for content promoting the use of herbal cigarettes. On TikTok, using the youth friendly terms ‘herbal cigarette’, ‘smokable herbs’, ‘smoke roses’, and ‘herbalism’, we identified 103 video postings with over 100,000 views published between September 2016 and August 2, 2022, promoting the use of herbal cigarettes garnering a total of 115.6 million views. In addition, we identified the top 100 ranked posts on Reddit’s largest herbal cigarette community, ‘smokingherbs’ on July 21, 2022. Over one-fourth (28%) featured misleading health claims associated with herbal cigarettes. Only one post from our sample included a disclaimer of potential harms. Similarly, we searched Instagram on July 24, 2022, for the top 50 ranked posts under the hashtag #herbalcigarette. Nearly half (44%) of these posts featured misleading health claims and 84% were published by businesses marketing their products.

A common misconception is that the harmful toxicants in hookah smoke (and even more so for herbal hookah products) are filtered out as it passes through water (18). The availability of sweet candy-like flavours coupled with misleading labeling such as ‘additive-free’ and ‘natural herbs’ contribute to the notion that herbal hookah products are a safer alternative to tobacco containing products and may particularly entice youth to consume these products. These labels can generate a false sense of security with users extrapolating that by being free of one given toxicant, the product is free of all toxicants. In fact, over one-third (37.6%) of 9th to 12th graders in Canada believe that hookah use (herbal or tobacco) is less harmful than conventional cigarettes (19). These misperceptions are dangerous as youth may gravitate toward herbal smoking products as smoking cessation aids (despite lack of evidence supporting this) or as a safer way of using hookah, and thus inadvertently exposing themselves to harmful chemicals and carcinogens.

REGULATIONS

Herbal smoking products such as herbal cigarettes and herbal shisha do not fall under the purview of the Tobacco & Vaping Control Act as they do not contain tobacco (20). In fact, there are no federal regulations in place with regards to labeling, sales to minors, promotion, or flavourings for such products. Unlike cigarettes, herbal smoking products can have colorful, aesthetically pleasing packaging that may appeal to youth. Furthermore, herbal cigarettes can easily be home-made with blunt wraps or rolling paper and as such are not required to don health warnings under current federal regulations (21).

In Canada, tobacco product manufacturers are required to report detailed information on their constituents and emissions (22). However, herbal smoking products are not subject to such regulations and labeled ingredient information is often scarce and ambiguous (4).

All provinces and territories have smoke-free legislation in place prohibiting smoking tobacco indoors in public spaces. Hookah cafés have found ways to circumvent such laws by claiming to only sell herbal non-tobacco shisha. To address this, five provinces (NB, NS, NL, PEI, QC), all three territories and dozens of municipalities (Vancouver, Ottawa, Toronto, Edmonton, etc.) have prohibited all waterpipe smoking, including herbal shisha, in places where smoking is prohibited (23). Nonetheless, hookah establishments continue to benefit from regulatory loopholes through herbal shisha in many parts of Canada, and only Quebec and Nunavut have laws prohibiting the sale of flavoured herbal smoking products (24,25).

Regulating hookah establishments can be challenging as some proprietors anecdotally create their own blends adding liquid nicotine (e-juice) to herbal shisha or energy drinks in lieu of water (4,26). In fact, inspections of hookah establishments in Ottawa in 2011 found that 19 of the 20 were selling tobacco smoking products despite only legally being allowed to sell herbal shisha (27). Herbal smoking products are also widely available for purchase online with dubious health claims and lack of age restrictions (28). Some hookah establishments have called on the ethnocultural significance of hookah to obtain exemptions from clean air regulations, citing the origins of hookah tracing back centuries to the Middle East and South Asia (9). The ethnocultural significance of hookah has been debated as most hookah users with Middle Eastern backgrounds do not consider their hookah use to be intrinsically linked to their culture (9).

IMPLICATIONS FOR POLICY AND PRACTICE

Health lobby groups have advocated for increased control and regulations of herbal smoking products with proposed amendments to the Tobacco Act and Consumer Product Safety Act. Though these efforts have yet to lead to changes in legislation, the federal government could consider following the example of Quebec and Nunavut and expand the regulatory framework to include herbal smoking products in tobacco product regulations. Paediatricians can also play a key role in educating youth and families about the harms of these products. Providers can ask their patients about use of herbal smoking products when they screen for use of tobacco and other substances. Providers should also be aware of the higher prevalence of hookah use among youth of Middle Eastern descent and approach cessation discussions with an understanding of the historical and modern contexts of hookah smoking (4,9). In addition, given the omnipresence of false claims and misinformation around herbal smoking products, there is a significant need for large-scale public health campaigns cautioning against the harms of these products. These campaigns could include media literacy education designed with and for youth to help them recognize the pervasive and misleading marketing tactics that companies use to make their products appear safe.

CONCLUSION

As tobacco and e-cigarette regulations become increasingly stringent and comprehensive, herbal smoking products have the potential to become more mainstream. Herbal smoking products are poorly regulated, easily accessible and emit harmful toxicants. There is an urgent need to collect epidemiological data to better understand the scope of use among youth. Furthermore, more research is needed on the harms associated with these products to better educate and inform providers and the public. Though often marketed as health products, herbal cigarettes and shisha should not be used as smoking cessation or harm reduction tools given the known risks and lack of evidence to support their use.

FUNDING

NC is funded by a Fonds de Recherche du Québec (FRQ) – Santé Clinician Research Scholar Award (Junior 1).

POTENTIAL CONFLICTS OF INTEREST

NC is supported by a Clinical Research Scholar Award from the Fonds de Recherche du Québec (Santé). There are no other disclosures. All authors have submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest. Conflicts that the editors consider relevant to the content of the manuscript have been disclosed.