By Michael Woldeyes LLM, International Human Rights Law, mengistumichael@gmail.com

Khat is an evergreen plant whose leaves are masticated for their stimulant purposes. It is mainly cultivated in East Africa and Yemen and its leaves contain chemicals such as Cathinone (categorized as a schedule 1 drug in the United States), Cathine, and Norephedrine which give fresh khat leaves their most sought-after stimulant effects.[1] The consumption of Khat has been controversial for many years. Its use and trade are banned in many western countries[2] while it is a completely legitimate commodity in countries such as Ethiopia, Kenya, and Yemen. Economic benefits gained from the drug through export and domestic sell are one of the major causes for its free trade in these countries. For example, Khat is one of the top exported crops of Ethiopia.[3] On the other hand, the USA and the UK, amongst others, have criminalized the drug, stating various reasons. For example, the USA banned khat on the ground that it induces “manic behavior with grandiose delusions, paranoia, nightmares, hallucinations and hyperactivity”.[4] Similarly, the UK banned the use of khat in 2014 citing potential health and social harms associated with the drug.[5]  Nevertheless, WHO’s Expert Committee on Drug Dependence decided in 2006 that khat should not be subject to treaty-based prohibition stating that “the potential for abuse and dependence is low”.[6] On the contrary the International Narcotics Control Board of the UN calls for the control of the drug by stating that khat includes chemicals that are scheduled under UN drug control.[7]

It has been 15 years since the WHO researched khat and decided not to subject it for a treaty-based prohibition. However, several research on the mental and physical health effects of khat have been published within these fifteen years and as shown above, many countries have moved to ban the drug. So, is there a need for the WHO to reopen discussions on khat? This blogpost tries to answer this question by first describing the health effects of khat.

How does khat affect the health of individuals?

Several studies that are conducted in top khat producing and consuming countries show that khat is a risk-factor for cardiovascular diseases which are “the number 1 cause of death globally, taking an estimated 17.9 million lives each year” [8] and mental health. Studies also show that khat serves as a gateway for tobacco use which kills more than eight million people each year.[9] The following paragraphs describe study findings on the mental and physical health of khat.

Khat and mental illness

Various studies conducted in East Africa and other countries show that khat use is associated with mental illness.[10] A study conducted on the Amhara region of North West Shewa discovered that of all the khat chewers the study examined, 43% were khat dependent. Furthermore, prevalence of depression, anxiety, and stress was higher among khat chewers.[11] In another study, among 70 male khat chewers, 52% of them were found to be dependent on the plant while another study conducted on 619 students discovered that 68.2% of the study participants had experienced different withdrawal symptoms when they tried to quit the habit.[12] According to the latter study, “the most frequently reported withdrawal symptoms were feeling depressed (65.3%), craving (44.6%), feeling fatigued (36.6%), increased appetite (29.7%), irritability (26.7%) hypersomnia (20.8%) and nightmares (20.8%)”.[13] Khat chewers were also reported to have mental distress.[14]

Khat as a risk factor for cardiovascular diseases

Khat consumption has also been found to result in cardiovascular diseases. A research conducted on 8,176 patients in six Middle Eastern countries discovered that khat results in elevated blood pressure and heart rate.[15] The study also shows that khat chewers are more vulnerable to other cardiovascular diseases such as myocardial infarctions than non-chewers.[16] This finding mirrors another finding of a study which took place in Southern Ethiopia. The latter study examined 1,198 participants and demonstrated that there was a significant association between khat chewing and elevated blood pressure.[17] Researchers associate the increase in blood pressure and heart rate seen in khat chewers to the cathinone element of khat.[18] Another study which was conducted on 100 patients in Yemen over a period of two years concluded that Khat chewers are at risk of acute myocardial infarctions commonly known as a heart attack.[19] The study also shows that the vulnerability of the khat chewers to cardiovascular diseases increase as the number of khat chewing hours and the chewing volume increases. Hence, daily khat chewers are more at risk than those who chew khat occasionally.[20] Similarly, a review article which analyzed 52 publications on the health effects of khat found out that khat use has a direct effect on cardiovascular system and puts khat users at a high risk of myocardial infarction and cardiac arrhythmias.[21] Another study which synthesized 10 publications on the same subject shows that “khat chewing in different countries is associated with high blood pressure and elevated heart rate, which are established risk factors for cardiovascular diseases”.[22]

Khat as a gateway for tobacco use

Besides being a risk factor on its own, khat is known to be a gateway for tobacco use. This has been affirmed in a study which was conducted on 401 individuals in Yemen.[23] This finding is concurrent with another similar study which was undertaken in the UK on adult male khat chewers. This study concluded that “one of the most common consequences of khat chewing is tobacco uptake”[24] and that “the overall consensus based on emerging evidence is that khat may be a gateway drug to tobacco”.[25] According to another study, khat use serves as a gateway for tobacco use because khat is often chewed in groups where tobacco use is prevalent and because of the fact that khat users believe that tobacco enhances the needed effects of khat.[26] In addition to being a killer by itself, studies have shown that tobacco exacerbates the negative effects of khat on the cardiovascular system.[27]

Should the WHO reopen discussions on khat?

The developments in research in main khat producing and consuming countries and other parts of the world in the last decade show that khat is more dangerous than it was initially thought to be. We can see from these studies that in addition to being a risk factor for cardiovascular diseases, the potential for khat abuse and dependence might be higher. Moreover, the studies also show that khat introduces to tobacco use which seems to be more dangerous and addictive than khat itself. Hence, in conclusion, I believe that there is enough ground for the WHO to reopen discussions on khat.

[1] Alemu Gebrie, Animut Alebel, Abriham Zegeye, Bekele Tesfaye, “Prevalence and Predicators of Khat Chewing among Ethiopian University Students: A Systematic Review and Meta-analysis” 13 (4) PLoS ONE, 2.

[2] Khat is banned in most European countries including the UK, France and the Netherlands; it is banned in most Asian and Arab countries such as China, South Korea, and Saudi Arabia; it is also banned in the US.

[3] See for example National Bank of Ethiopia, Quarterly Bulletin, Fourth Quarter 2019/2020 Fiscal Year Series (Vol 36 No. 4), 37.

[4] US Drug Enforcement Agency, Drug Fact Sheet: Khat, 1.

[5] UK Home Office, Khat Fact Sheet for England and Wales (2014), 1.

[6] WHO Expert Committee on Drug Dependence, WHO Technical Report Series (2006 34^th report) 11.

[7] Transnational Institute, Scheduling in the International Drug Control System, (2014), 14.

[8] WHO, Cardiovascular Diseases, <https://www.who.int/health-topics/cardiovascular-diseases#tab=tab_1> accessed on November 05, 2021.

[9] WHO, Tobacco <https://www.who.int/news-room/fact-sheets/detail/tobacco> accessed on November 05, 2021.

[10] See also WHO, UN Task Force on NCDs: The Government of Ethiopia is Working Jointly with the UN System to Strengthen the National NCD Response, <https://www.who.int/ncds/un-task-force/joint-programming-missions/ethiopia-november-2017/en/> accessed on November 05, 2021.

[11] Seife Asrade Atnafie, Niguse Yigzaw Muluneh, Kefyalew Ayalew Getahun, Asegedech Tsega Woredekal, and Wubayehu Kahaliw, “Depression, Anxiety, Stress, and Associated Factors among Khat Chewers in Amhara Region, Northwest Ethiopia” [2020] 2020 Hindawi, 11. Dependence on khat was also reported in the UK. See Suhana Begum, Angeliki Bogosian, and Hayley McBain, “The Experiences of People Who Quit Khat and the Health Care Professionals Who Support Them” [2019] 11 (4) Addiction and Health, 9.

[12] Maged El-Setouhy, Rashad M. Alsanosy, Abdallah Alsharqi, and Ahmed A. Ismail, “Khat Dependency and Psychological Symptoms among Chewers in Jazan Region, Kingdom of Saudi Arabia” [2016] 2016 BioMed Research International, 3. See also Tilahun Abdeta, Daniel Tolessa, Kirstina Adorjan, and Mubarek Abera, “Prevalence, Withdrawal Symptoms, and Associated Factors of Khat chewing Among Students at Jimma University in Ethiopia” [2017] 17 (142) BMC Psychiatry, 6.

[13] Tilahun Abdeta, Daniel Tolessa, Kirstina Adorjan, and Mubarek Abera, “Prevalence, Withdrawal Symptoms, and Associated Factors of Khat chewing Among Students at Jimma University in Ethiopia” [2017] 17 (142) BMC Psychiatry, 6.

[14] Tekalign Damena, Andualem Mossie, and Markos Tesfaye, “Khat Chewing and Mental Distress: A Community Based Study, in Jimma City, Southwestern Ethiopia” [2011] 21 (1) Ethiopian Journal of Health Science, 44.

[15] Waleed M. Ali, Mohammad Zubaid, Ahmed Al-Motarreb et al., “Association of Khat Chewing with Increased Risk of Stroke and Death in Patients Presenting with Acute Coronary Syndrome” [2010] 85 (11) Mayo Clinic Proceedings, 5.

[16] Ibid 6.

[17] Teshome Gensa Geta, Gashaw Garedew Woldeamanuel, Bereket Zeleke Hailemariam, Diribsa Tsegaye Bedada, “Association of Chronic Khat chewing with Blood Pressure and Predictors of Hypertension” [2019] 12 Integrated Blood Pressure Control, 20136. Similar outcomes were shown in other studies. See N. A. Hassan, A. A. Gunaid, A. A. Abdo-Rabbo, Z. Y. Abdel-Kader, M. A. Al-Mansoob, A. Y. Awad, and I. M Murray-Lyon, “The effect of Qat Chewing on Blood Pressure and Heart Rate in Healthy Volunteers” [2000] 30 (2) Tropical Doctor Journal, 107. Yeweynhareg F. Gebreyes, Dejuma Y. Goshu, Tedla K. Geletaw, Terefe G. Argefa, Theodros G. Zemedu, Kassahun A. Lemu et al., “Prevalence of High Blood Pressure, Hyperglycemia, Dyslipidemia, Metabolic Syndrome and Their Determinants in Ethiopia: Evidences from the National NCDs STEPS Survey 2015” [2018] 13 (5) PLoS ONE, 4. Fekeru Tesfaye, Peter Byass, Yemane Berhane, Ruth Bonita, Stig Wall, “Association of Smoking and Khat (Catha edulis Forsk) Use with High Blood Pressure Among Adults in Addis Ababa Ethiopia” [2008] 5 (3) Preventing Chronic Disease – Public Health Research, Practice, and Policy, 3.

[18] Nasir Tajure Wabe, “Chemistry, Pharmacology, and Toxicology of Khat (Catha Edulis Forsk): A Review” [2011] 3 (3) Addiction and Health, 4. See also Abdul-Kafi Shujaa and Wail Nammas, “Khat chewing and Cardiovascular Risk Profile in a Cohort of Yemeni Patients with Angiographically Documented Coronary Artery Disease” [2012] 4 (1) Heart Asia, 2-5.

[19] A. Al-Motarreb, S. Briancon, N. Al-Jaber, B. Al-Adhi, F. Al-Jailani, M S. Salek and K J. Broadley, “Khat Chewing is a Risk Factor for Acute Myocardial Infarction: A Case-Control Study” [2005] 59 (5) British Journal of Clinical Pharmacology, 3. See also Harvard Health Publishing, Heart Attack (Myocardial Infarction), <https://www.health.harvard.edu/a_to_z/heart-attack-myocardial-infarction-a-to-z> accessed on November 05, 2021.

[20] Ibid.

[21] Molla Abebe, Samuel Kindie and Kasaw Adane, “Adverse Health Effects of Khat: A Review” [2015] 4 (1) Family Medicine and Medical Science Research, 3. And Iana Malasevskaia, Ahmed A. Al-Awadhi, and Lubna Mohammed, “Tea in the Morning and Khat Afternoon: Health Threats Due to Khat Chewing” [2020] 12 (12) Cureus, 3), 2.

[22] Teshale Ayele Mega and Nikodimos Eshetu Dabe, “Khat (Catha Edulis) as a Risk Factor for Cardiovascular Disorders: Systematic Review and Meta-Analysis” [2017] 11 The Open Medical Journal, 151.

[23] Motohiro Nakajima, Anisa Dokam, Najat Saem Khalil, Mohammed Alsoofi, and Mustafa al’Absi, “Correlates of Concurrent Khat and Tobacco Use in Yemen” [2017] Substance Use and Misuse, 6.

[24] Saba Kassim, Nikki Rogers, Kelly Leach, “The Likelihood of Khat Chewing Serving a Neglected and reverse

‘Gateway’ to tobacco use among UK Adult Male Khat Chewers: A Cross Sectional Study” [2014] 14 (448) BMC Public Health, 2.

[25] Ibid 4.

[26] Saba Kassim, Mohammed Jawad, Ray Crucher and Elie A. Akl, “The Epidemiology of Tobacco Use among Khat Users: A Systematic Review” [2015] 2015 BioMed Research International, 6.

[27] Molla Abebe, Samuel Kindie and Kasaw Adane (n 20), 2. See also Motohiro Nakajima, Anisa Dokam, Najat Saem Khalil, Mohammed Alsoofi, and Mustafa al’Absi (n 22), 9.