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Tobacco Induced Diseases

Open Access

Perceptions of hookah smoking harmfulness: predictors and characteristics among current hookah users

Tobacco Induced Diseases20095:16

https://doi.org/10.1186/1617-9625-5-16

Received: 23 September 2009

Accepted: 18 December 2009

Published: 18 December 2009

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Archived Comments

  1. Hookah Smoking Harmfulness : Correcting a Few Errors and Clarifying Some Points of Interest

    20 January 2010

    Kamal Chaouachi, DIU Tabacologie, Universite Paris XI (France)

    Dear Editor,

    NICOTINE. Aljarrah et al state that “scientific facts indicate
    that” when compared to cigarette smoking "hookah smoke also contains
    36 times the amount of nicotine” [1]. The authors cite for
    this purpose two papers from the US-American University of Beirut. In
    fact, this elevated figure is not that that for nicotine and it should
    be divided by at least 18. Indeed, there is a growing consensus among
    tobacco control researchers that one hookah session would not deliver
    more nicotine than one single cigarette.

    TEMPERATURES. There is also another error concerning the working
    temperatures. 900°C is a common figure for the temperature at the tip
    of a cigarette, not inside the hookah bowl as Aljarrah et al state.
    450°C is the temperature of the glowing charcoal (of the quick self-lighting
    type). It should be noted that there is a thermal foil screen separating
    the heating source from the mixture so the temperature inside the bowl
    hardly goes in excess of 200°C. Furthermore, tobacco (or, more properly,
    the tobacco-molasses based mixture) does not burn in a hookah bowl but
    is simply heated. These points were clarified in a commentary about
    the WHO report cited by the authors [2].

    ORIGINS. The WHO report mentions the 16th century and not the
    previous one put forward by Aljarrah et al. In any case, the same above-mentioned
    commentary suggested, among others, a chief archaeological reference
    showing that water pipes were dug out in Eastern Africa two centuries
    before [3].

    GENDER USE. Aljarrah et al state that “late in the 19th century,
    hookah use started spreading among women in the Middle East". However,
    the use by women is as old as the invention of the device. A prestigious
    Syrian female lung specialist who has been studying this practice for
    two decades, clearly shows that women in this region “have been smoking
    narguileh water pipes for centuries”[4].

    SECOND-HAND SMOKE. This problem should not be exaggerated and
    the focus should remain on the hazards of active hookah smoke, i.e.
    the one inhaled by the smoker. Indeed, US researchers have early pointed
    out that “one of the only articulated benefits to this tobacco alternative
    is the minimal release of side-stream smoke, which would ultimately
    place by-standers at risk for ETS exposure” [5].

    GATEWAY HYPOTHESIS. This hypothesis (switching from hookah to
    cigarette use) is acceptable. However, one should not omit to mention
    negative results such as those from an important recent Australian survey
    involving a large sample. Its authors conclude that they “are not
    alarmed about potential switching as only one ex-CCP [Cigarette/Cigar/Pipe]
    smoker (out of 1,102 respondents) also reported smoking WT [Water pipe
    Tobacco] on a daily basis” [6].

    ________________

    REFERENCES

    [1] Aljarrah K, Ababneh ZQ, Al-Delaimy WK. Perceptions of hookah smoking harmfulness: predictors and characteristics among current hookah users. Tob Induc Dis. 2009 Dec 18;5(1):16. [Epub ahead of print]

    http://www.tobaccoinduceddiseases.com/content/5/1/16

    [2] 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/pdf/1477-5751-5-17.pdf

    [3] Van Der Merwe NJ: Cannabis Smoking in 13th-14th Century Ethiopia: Chemical Evidence. In World Anthropology: Cannabis and Culture. Edited by Vera Rubin: Mouton Publ. (The Hague); 1975: 77-80.

    [4] Mohammad Y, Kakah M, Mohammad Y. Chronic respiratory effect of narguileh smoking compared with cigarette smoking in women from the East Mediterranean region. Int J Chron Obstruct Pulmon Dis. 2008;3(3):405-14.

    [5] Deckers SK, Farley J, Heath J. Tobacco and its trendy alternatives: implications for pediatric nurses. Crit Care Nurs Clin North Am 2006 (Mar);18(1):95-104.

    [6] Carroll T, Poder N, Perusco A. Is concern about waterpipe tobacco smoking warranted? Aust N Z J Public Health. 2008 Apr;32(2):181-2.

    Competing interests

    no competing interests.

  2. Hookah Smoking Harmfulness: Correcting a Few Errors and Clarifying Some Points of Interest

    16 February 2010

    Kamal Chaouachi, DIU Tabacologie, Université Paris XI (France)

    Dear Editor,

    NICOTINE. Aljarrah et al state that “scientific facts indicate that “when compared to cigarette smoking […]”, "hookah smoke also contains 36 times the amount of nicotine” [1]. The authors cite for this purpose two papers from the US-American University of Beirut. In fact, this elevated figure is not that that for nicotine and it should be divided by at least 18. Indeed, there is a growing consensus among tobacco control researchers that one hookah session would not deliver more nicotine than one single cigarette.

    TEMPERATURES. There is also another error concerning the working temperatures. 900°C is a common figure for the temperature at the tip of a cigarette, not inside the hookah bowl as Aljarrah et al state. 450°C is the temperature of the glowing charcoal (of the quick self-lighting type). It should be noted that there is a thermal foil screen separating the heating source from the mixture so the temperature inside the bowl hardly goes in excess of 200°C. Furthermore, tobacco (or, more properly, the tobacco-molasses based mixture) does not burn in a hookah bowl but is simply heated. These points were clarified in a commentary about the WHO report cited by the authors [2].

    ORIGINS. The WHO report mentions the 16th century and not the previous one put forward by Aljarrah et al. In any case, the same above-mentioned commentary suggested, among others, a chief archeological reference showing that water pipes were dug out in Eastern Africa two centuries before [3].

    GENDER USE. Aljarrah et al state that “late in the 19th century, hookah use started spreading among women in the Middle East". However, the use by women is as old as the invention of the device. A prestigious Syrian female lung specialist who has been studying this practice for two decades, clearly shows that women in this region “have been smoking narguileh water pipes for centuries” [4].

    SECOND-HAND SMOKE. This problem should not be exaggerated and the focus should remain on the hazards of active hookah smoke, i.e. the one inhaled by the smoker. Indeed, US researchers have early pointed out that “one of the only articulated benefits to this tobacco alternative is the minimal release of side-stream smoke, which would ultimately place by-standers at risk for ETS exposure” [5].

    GATEWAY HYPOTHESIS. This hypothesis (switching from hookah to cigarette use) is acceptable. However, one should not omit to mention negative results such as those from an important recent Australian survey involving a large sample. Its authors conclude that they “are not alarmed about potential switching as only one ex-CCP [Cigarette/Cigar/Pipe] smoker (out of 1,102 respondents) also reported smoking WT [Water pipe Tobacco] on a daily basis” [6].

    ________________

    REFERENCES

    [1] Aljarrah K, Ababneh ZQ, Al-Delaimy WK. Perceptions of hookah smoking harmfulness: predictors and characteristics among current hookah users. Tob Induc Dis. 2009 Dec 18;5(1):16. [Epub ahead of print]

    http://www.tobaccoinduceddiseases.com/content/5/1/16

    [2] 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/pdf/1477-5751-5-17.pdf

    [3] Van Der Merwe NJ: Cannabis Smoking in 13th-14th Century Ethiopia: Chemical Evidence. In World Anthropology: Cannabis and Culture. Edited by Vera Rubin: Mouton Publ. (The Hague); 1975: 77-80.

    [4] Mohammad Y, Kakah M, Mohammad Y. Chronic respiratory effect of narguileh smoking compared with cigarette smoking in women from the East Mediterranean region. Int J Chron Obstruct Pulmon Dis. 2008;3(3):405-14.

    [5] Deckers SK, Farley J, Heath J. Tobacco and its trendy alternatives: implications for pediatric nurses. Crit Care Nurs Clin North Am 2006 (Mar);18(1):95-104.

    [6] Carroll T, Poder N, Perusco A. Is concern about waterpipe tobacco smoking warranted? Aust N Z J Public Health. 2008 Apr;32(2):181-2.

    Competing interests

    no competing interests.

  3. Response to Comments by Dr. Kamal Chaouachi

    16 February 2010

    Khaled Aljarrah, Jordan University of Science and Technology

    We thank Dr. Chaouachi for providing valuable comments on our article and finding two typos that we missed. The first typo was calculating and using the number 36 when it should be 3.8 in the statement “hookah smoke also contains 36 times the amount of nicotine” based on table 2 in the reference by Shihadeh 2005 [1] that we cite. The second typo is mistakenly switching 900 with 450 and 450 with 900 for the respective temperature of cigarettes and hookahs [2].
    For the other points raised by Dr. Chaouachi we do have different explanations and understandings based on the published literature. Under his comment titled “NICOTINE”, we do not agree that one hookah session would not deliver more nicotine than one single cigarette [3, 4]. We also disagree with his comment titled “TEMPERATURES” that the temperature inside the bowl hardly goes in excess of 200 °C because Shihadeh’s experiment measures a 450 °C temp for the tobacco nearest to the heat source in the hookah and not 200°C [2].
    His comment titled “ORIGINS “ about the origins of hookah going back to earlier years than we report, cites a reference to a book that we do not have access to and we quote official and accessible WHO documents. Furthermore, it was reported by Karen Stephenson about the history of the hookah as “hookah got their origin in the North West part of India almost one thousand years ago” but it was modernized during the Mughal Reign (1500) to be similar to what we now know and then underwent further changes afterwards [5]. Therefore, it could be in many other older forms in earlier times. For the “GENDER USE” comment; our statement says « started spreading » meaning it became more common. This does not exclude that women started smoking it prior to that, as mentioned by Dr. Chaouachi. In terms of “SECOND-HAND SMOKE”, we don’t feel we are exaggerating this problem for hookah, but we think that hookah side-stream smoke (SSE) should receive more attention. Recently a publication by Monzer B. et. al. conclude that a very high percentage of CO and high yields of PAH are produced by charcoal used for smoking hookah [6]. Moreover, we think that there should be a focus on the risk associated with the SSE from hookah per se rather than in comparison to cigarette SSE. The experiment by Maziak et al 2008 clearly demonstrated a very high particulate matter from side stream smoke of hookah that was comparable or higher than cigarettes [7]. In our observation when carrying out the study in hookah lounges the rooms were filled with smoke.

    Finally, in terms of the “GATEWAY HYPOTHESIS” of people switching from hookah to cigarettes, this is a very strong and dangerous possibility given the levels of nicotine produced by one hookah session. The study cited by Dr. Chaouachi that failed to find people switching still suggest strategies to control hookah because half of the users are currently nonsmokers (i.e they can switch and become smokers).

    As with any new field, hookah-related research is still under development and varying accounts and interpretations are acceptable. We therefore thank Dr. Chaouachi for his contribution and comments.


    References


    1. Shihadeh A, Saleh R: Polycyclic aromatic hydrocarbons, carbon monoxide, "tar", and nicotine in the mainstream smoke aerosol of the narghile water pipe. Food and Chemical Toxicology 2005, 43(5):655-661.
    2. Shihadeh A: Investigation of mainstream smoke aerosol of the argileh water pipe. Food and Chemical Toxicology 2003, 41(1):143-152.
    3. Macaron C, Macaron Z, Maalouf M, Macaron N, Moore A: Urinary cotinine in narguila or chicha tobacco smokers. The Lebanese medical journal 1997, 45(1):19 -20.
    4. Neergaard J, Singh P, Job J, Montgomery S: Waterpipe smoking and nicotine exposure: a review of the current evidence. Nicotine & Tobacco Research 2007, 9(10):987 994.
    5. BMC
    6. Monzer B, Sepetdjian E, Saliba N, Shihadeh A: Charcoal emissions as a source of CO and carcinogenic PAH in mainstream narghile waterpipe smoke. Food and Chemical Toxicology 2008, 46(9):2991-2995.
    7. Maziak W, Rastam S, Ibrahim I, Ward KD, Eissenberg T: Waterpipe-associated particulate matter emissions. Nicotine & Tobacco Research 2008, 10(3):519-523.

    Competing interests

    No competing interests.

  4. Time to Make Tabula Rasa of Some Misconceptions in Research on Hookah (Narghile, Shisha) Tobacco Smoking

    2 July 2010

    Kamal Chaouachi, DIU Tabacologie, Université Paris XI (France)

    PLAN: Introduction; 1) Smoking machines ; 2) Nicotine intake ; 3) Temperatures involved; 4) Origins; 5) Second hand smoke ; 6) Gateway hypothesis; Conclusion.

    Introduction. The high degree of international confusion surrounding hookah research, likely never reached in the history of tobacco research, is mainly due to the abuse of smoking machines and the use of a reductionist nominalism (““waterpipe””)[1].

    1) While biomedical research on hookah smoking is very old and particularly informative, it is surprising that the arguments of ““waterpipe”” antismoking researchers almost exclusively rely on levels of toxic substances produced by smoking machines operated at the US-American University of Beirut (US-AUB)(Shihadeh, Saleh, Sepetjian, Monzer, Saliba, Daher, and others: 2003-2009). However, the corresponding laboratory modelling of a complex human behaviour (smoking) is seriously biased as it is clear that a hookah smoker is not a robot drawing a puff every 17s, with the charcoal placed in the same point atop the bowl, over a full hour [1][2][3].

    2) The concern over nicotine is directly related to the uncritical use of the confusing ““waterpipe”” neologism put forward by the US-Syrian Centre for Tobacco Studies (US-SCTS)[1]. The global mix-up reached its climax with Neergaard et al.’s metaanalysis in which the pooled studies, among other biases, involved different products for a direct comparison [1]. Of course, nicotine “compensation” is possible but Macaron et al’ study was about plain tobacco (tumbak/ajamy), not the fashionable flavoured smoking gooey mixture called moassel/tobamel(30% tobacco or less, or no tobacco at all). However, the ““waterpipe”” nominalism has elicited such a generalisation, hence the witnessed confusion. There is not a single ““waterpipe”” model but a very wide variety of pipes with diverse smoking products which, in their turn, produce smokes of dissimilar volumes, chemical compositions and health effects. Comparisons with cigarette are irrelevant and unscientific [1].

    Interestingly, antismoking researchers have recently published a study (certainly not the first one on this issue as its authors claim) involving human subjects and found what we already know for decades now: i.e., that the mean blood nicotine level in hookah smokers sitting for a 45 min session was lower than that found in cigarette users after having smoked a single cigarette [4]. Furthermore, the same study on blood nicotine gives credit to the critique of the US-AUB smoking machine [3]. For instance, by contrast with the unrealistic inter-puff time (17s), an average of 43s was found for this important parameter in a situation a bit closer to real smoking. This huge difference in the smoking “pace” has not less dramatic consequences on the levels of tar.

    3) Confusion about temperatures is unfortunately too frequent. 450°C, or more, is the temperature of the glowing charcoal, not of moassel. Inside the bowl, the temperature does not go, on average, in excess of 200°C [3]. The main function of the aluminium foil is that of a thermal screen. Compared to cigarettes (tip: 900°C), potentially high different chemical and health consequences are expected to be found.

    4) The most “official” scientific peer-reviewed English language reference regarding the origins of the hookah is Van der Merwe (1975). It offers chemical evidence about the actual use of water pipes in Africa long before the “official” date imposed to the world in the WHO report authored by the US-AUB and US-SCTS teams (Thomas Eissenberg, Alan Shihadeh and Wasim Maziak). As with many other reports from the WHO, the above one is strongly biased [5][6]. Its first two sentences addressing the origins of the device contain serious errors and misquotations. Citing non-peer reviewed online articles of the popular press (e.g. Karen Stephenson) is not an alternative.

    5) From early peer-reviewed studies in Saudi Arabia (King Abdulaziz University) and not only recent US-AUB papers, we know that the main source of polycyclic aromatic hydrocarbons and heavy metals is the charcoal. These publications have been systematically dismissed by ““waterpipe”” antismoking researchers obviously because of their “negative” results [7][8]. Research on hookah smoking has no commenced in 2002 as the US-SCTS claimed. Most of what we know today about hookah smoking have been thoroughly studied by independent (from both the tobacco and pharmaceutical industries) researchers long before year 2002 [1].

    A study by Maziak et al about smoke particulate matter is often cited without drawing attention to its many biases and to the fact that, in spite of the latter, the experiment revealed that hookah smoke is much less concentrated in particles than cigarette smoke [9]. Furthermore, the authors themselves noted that "smoldering of waterpipe, however, did not seem to contribute to indoor particulate matter, in sharp contrast to what is witnessed with cigarette smoking".

    Certainly, modern hookah lounges always call forth the image of huge clouds of smoke. However, this is mostly exhaled mainstream smoke, not side-stream smoke. That smoke has been filtered twice: inside the hookah apparatus itself and then in the respiratory tract of the smoker. This optic illusion is too frequent in the ““waterpipe”” literature and finds its source in the systematic unscientific paralleling between cigarette and hookah [9].

    Recently, two other studies on this issue have been published. One of them was led in Germany with human volunteers while the other, experimental, was published in Atmospheric Environment (University of East Anglia). Unfortunately, both posed serious ethical and/or methodological problems that have been brought out [1][10][11].

    6) With such a low nicotine intake (Point 2), the possibility of switching from hookah to cigarettes remains very uncertain. However, the hypothesis is acceptable as long as any sound study on this issue will be based on not less sound questionnaires, unlike those inappropriate ones used by Rice et al. at the University of Michigan [12].

    Conclusion. Tobacco, and particularly tobacco smoking, is dangerous. However, the global problem independent researchers will have to deal with is publication bias and a form of counterproductive monopoly against the background of a world epidemic.

    ____________

    REFERENCES:


    [1] Chaouachi K, Sajid KM. A critique of recent hypotheses on oral (and lung) cancer induced by water pipe (hookah, shisha, narghile) tobacco smoking. Med Hypotheses 2009 (online: 24 Dec).

    http://dx.doi.org/10.1016/j.mehy.2009.11.036

    [2] Bacha ZA, Salameh P., Waked M. Saliva Cotinine and Exhaled Carbon Monoxide Levels in Natural Environment Waterpipe Smokers. Inhalation Toxicology 2007;19(9):771-7.

    [3] Chaouachi K. Public health intervention for narghile (hookah, shisha) use requires a radical critique of the related “standardised” smoking machine. Journal of Public Health [Springer Berlin/Heidelberg] 2009; 17(5): 355-9. Doi : 10.1007/s10389-009-0272-7.

    http://www.springerlink.com/content/58352477706011t0/

    [4] Eissenberg T, Shihadeh A. Waterpipe tobacco and cigarette smoking direct comparison of toxicant exposure. Am J Prev Med. 2009 Dec;37(6):518-23.

    [5] Oxman AD, Lavis JN, Fretheim A. Use of evidence in WHO recommendations. Lancet. 2007 Jun 2;369(9576):1883-9.

    http://ebmctiame.carebmc.net/download/1190701368_Full%20Text.pdf

    [6] Girard M. World Health Organization Vaccine Recommendations: Scientific Flaws, or Criminal Misconduct ? Journal of American Physicians and Surgeons 2006;11(1):22-3.

    http://www.jpands.org/vol11no1/girard.pdf

    [7] El-Aasar AM, El-Merzabani MM, Studies on Jurak Smoke. I. The organic constituents of jurak smoke. Journal of King Abdulaziz University (Science) 1991; 3: 169-81.

    http://www.kau.edu.sa/ShowRes_EN.aspx?Site_ID=320&RN=52336

    [8] El-Aasar AM, El-Merzabani MM, Ba-Akel H. Studies on Jurak Smoke: II. The metallic constituents of jurak paste and jurak smoke. Journal of King Abdulaziz University (Science) 1991; 3: 183-8.

    http://www.kau.edu.sa/ShowRes_EN.aspx?Site_ID=320&RN=52337

    [9] Chaouachi K. Hookah (Shisha, Narghile) Smoking and Environmental Tobacco Smoke (ETS). A Critical Review of the Relevant Literature and the Public Health Consequences. Int. J. Environ. Res. Public Health 2009; 6(2):798-843.

    http://www.pubmedcentral.nih.gov/articlerender.fcgi?tool=pubmed&pubmedid=19440416

    [10] Chaouachi K. Re: Findings on Waterpipe Second Hand Smoke. BMJ 2009 (11 Nov)

    http://www.bmj.com/cgi/eletters/335/7609/20#224837

    [11] Chaouachi K. Hookah (shisha, narghile, "water pipe") indoor air contamination in German unrealistic experiment. Serious methodological bias and ethical concern. Food Chem Toxicol. 2010 Jan 25. [Epub ahead of print]. Doi:10.1016/j.fct.2010.01.020

    http://dx.doi.org/10.1016/j.fct.2010.01.020

    [12] Rice VH, Weglicki LS, Templin T, Hammad A, Jamil H, Kulwicki A. Predictors of Arab American adolescent tobacco use. Merrill-Palmer Quarterly 2006;52: 327-42.

    Competing interests

    No financial or personal competing interest.

Authors’ Affiliations

(1)
Applied Physics Department, Jordan University of Science and Technology
(2)
Physics Department, Yarmouk University
(3)
Family & Preventive Medicine Department, University of California San Diego

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