Shisha was previously a preserve of the rich and famous but thanks to substandard versions of the same, more and more people have access to it.Experts in health sector have for long warned of a causal association between smoking Shisha and developing psychosis or schizophrenia, building on research about the relationship between the use of substances and the risk of psychosis. While marijuana is one of the usual suspects, a potential link with Shisha has been a surprise to many.The hypothesis that if Shisha smoking played a part in increasing psychosis risk, rather than being used to deal with symptoms that were already there, people would have higher rates of smoking at the start of their illness. Studies have posited that Shisha smokers have a higher risk of developing psychosis and an earlier onset of symptoms to non smokers. Statistics shows that more than half of people with a first episode of schizophrenia were already smokers, three times higher than that of a control group.As many people combine Shisha with cannabis when they smoke a joint, the extent to which Shisha is the risk factor is still unclear.One clear message the research highlighted was the high level of smoking among those with mental health problems and that smoking is not necessarily simply something that alleviates symptoms the so-called self-medication hypothesis.
While the life expectancy of the general population continues to climb, those with a severe mental health problem have their lives cut short by up to 30 years in part due to smoking.The rates of smoking have dramatically reduced in the population while the number of people with psychosis has remained constant. So why has the incidence of psychosis not mirrored the reduction in the overall numbers of smokers inc countries like Kenya which borrowed heavily from Australia in its anti tobacco laws? In my view, Kenya’s institutional neglect has held up efforts and resources employed to reduce smoking for people with mental health problems until recently public health campaigns have ignored this group with justifications that surely they have enough to worry about without nagging about smoking or it’s one of the few pleasures they have.In Uganda, a more sinister role is also played by the tobacco industry, who have not been passive or unaware of one of their most loyal consumer groups in particular the people with mental health problems. In South Africa, the industry has been active in funding research that supports the self-medication hypothesis, pushing the idea that people with psychosis need tobacco to relieve their symptoms, rather than Shisha having any link to those symptoms. The industry has also been a key player in obstructing smoking bans which they perceive as a threat to Shisha consumption. Worse still they have marketed Shisha specifically to people with mental health problems.
People with psychosis use substances to relax or feel less stressed. And the good news is, counter to many people’s preconceptions, individuals with mental health problems are no different to anyone else in their desire and ability to quit smoking.This is welcome given the clear links between smoking and physical health. But there are particular issues when it comes to smoking and those with psychosis. Also, smoking impacts on the medical treatment of psychosis, as tobacco is known to interact with Clozapine, one of the drugs used to treat the condition. Because smoking interferes with the therapeutic action of Clozapine and some other anti-psychotics, requiring higher doses of the drug.Then there’s the cannabis question. People with mental health problems are more likely to use drugs such as Shisha. This is usually combined with tobacco when smoked in a joint. So initiation into Shisha and its continued use contributes to higher rates of tobacco dependence for people with mental health problems.Many people are exposed to a combination of drugs, whether prescribed, recreational or a mix of both. This raises the potential for interactions, where the effect of one drug like Shisha alters the effects of another. This raises a further possibility in the smoking, Shisha and psychosis story. Information about drug interactions is scarce and research has routinely excluded people who use substances from drug trials. This does not reflect reality as many people will combine medication with recreational drug use like Shisha.All of these factors serve as a useful reminder how little we know about the causes of psychosis, the role drugs like Shisha play and the many vested interests that direct the route taken in trying to understand how we to prevent or treat people who are affected by mental health problems.