The global epidemic of waterpipe smoking
School of Public Health, University of Memphis, Syrian Center for Tobacco Studies, Browning Hall 112, 3820 DeSoto Avenue, Memphis, TN 38152-3340, United States
a b s t r a c ta r t i c l ei n f o
In the past decade waterpipe (WP) smoking (a.k.a. hookah, shisha, and narghile) has been steadily spreading
among the youth around the world. The allure of this tobacco use method for the youth can stem from its
pleasant smooth smoke, social ambience and the perception of reduced harm. The material in this review is
based on detailed Medline search for articles appearing especially in the past two years that are of relevance to
WP epidemiology, health and addictive effects, and WP-related tobacco control policies. It shows that WP
smoking is continuing to spread among the youth worldwide, and perhaps represents the second global
tobacco epidemic since the cigarette. Available evidence suggests that the prevalence of current (past month)
WP smoking range from 6 to 34% among Middle Eastern adolescents, 5%–17% among American adolescents,
and that WP use is increasing globally. Studies on the health effects of WP smoking are limited by meth-
odological quality, as well as by the novelty of WP epidemic relative to the long latency of important smoking-
related health outcomes. Still, research indicates substantial WP harmful effects similar to those of cigarettes,
as well as to the potential of providing a bridge to cigarette smoking or relapse. Developing effective
interventions to curb WP use among the youth requires a detailed understanding of how dependence
develops in WP users, and how it is shaped by WP's unique features such as the following; the predominantly
intermittent use with prolonged sessions, preparation time, accessibility, potent sensory cues, and convivial
experience of group use. It also requires assessing effective policy options such as factual and visible health
warnings on all its parts, as well as youth access and indoor smoking restrictions. WP smoking is currently
showing all signs of a burgeoning global epidemic with serious implications for public health and tobacco
control worldwide. Investment in research and policy initiatives to understand and curb WP use needs to
become a public health priority.
© 2010 Elsevier Ltd. All rights reserved.
Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Is WP use a global public health problem or is it a passing FAD? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Does WP smoking pose an important public health problem? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
3.1.WP's harmful potential . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
3.2.WP's addictive potential . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
3.3.The need to understand WP dependence in order to develop evidence-based treatments . . . . . . . . . . . . . . . . . . . . . . .
Conclusions and policy recommendations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Role of Funding Sources . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Contributors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Conflict of Interest . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Only some decade ago, including questions about the waterpipe
(WP; a.k.a. hookah, shisha, and narghile) in epidemiological studies of
tobacco use among the youth would have seemed unwarranted, even
in the Eastern Mediterranean (EM) region considered by many as the
cradle of this tobacco use method. Not including such questions
nowadays, no matter where the study is conducted, will likely be a
serious flaw. This reflects the dramatic changes in youth's tobacco use
patterns worldwide, with non-cigarette forms, led by the WP, are
becoming increasingly popular (Warren et al., 2009). In the most
Addictive Behaviors 36 (2011) 1–5
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common form of WP used nowadays, burned charcoal pieces are
placed on top of a perforated aluminum foil separating it from the
flavored tobacco mixture (a.k.a. Maassel), so when the smoker draws
air through the hose's mouthpiece, charcoal-heated air becomes
smoke as it passes the tobaccomixture and cools as it bubbles through
the water before inhalation by the smoker (Fig. 1) (Cobb, Ward,
Maziak,Shihadeh, & Eissenberg, 2010; Gatrad,Gatrad, & Sheikh, 2007;
Knishknowy & Amitai, 2005; Maziak, 2008; Maziak, Ward, Afifi
Soweid, & Eissenberg, 2004; Maziak, Ward, & Eissenberg, 2007;
Warren et al., 2009). These features, especially the passage of smoke
through water (erroneously referred to as “filtering”), underlie much
of the widespread misperception about WP's “reduced” harm and
addictiveness. Recent research suggests that WP smoking is addictive
and is associated with considerable harm (Akl et al., 2010; Cobb et al.,
2010; Gatrad et al., 2007; Knishknowy & Amitai, 2005; Maziak, 2008;
Raad et al., 2010). Unfortunately, evidence-based prevention and
treatment interventions still lag behind, as is the knowledge base that
can guide the development of such interventions (Maziak et al.,
2007). In this review I want to provide an update about the global WP
epidemicandtheevidenceaboutits harmfulpublichealth potential as
it pertains to the development of treatment and policy interventions
to curb its spread.
2. Is WP use a global public health problem or is it a passing FAD?
In recent years WP use has been witnessing a surge in popularity,
especially among the youth in the EM region. In combination, the
introduction of manufactured Maassel, reduced-harm perception,
flourishing café culture and mass media have perhaps created optimal
conditions for the thriving global waterpipe epidemic. For example,
results of the Global Youth Tobacco Survey (GYTS) involving data
from 16 countries and the Gaza Strip in the EM suggest that current
(past month) WP smoking range from 6 to 34% among 13–15 year
olds (Warren et al., 2009). In Karachi Pakistan, ever WP use was
reported by 27% of school students (n=646; mean age 15 years) and
54% of university students (n=450, mean age 21 years), while
current WP use was reported by 17% of school and 33% of university
students (Anjum, Ahmed, & Ashfaq, 2008; Jawaid et al., 2008). Among
Jordanian university students (n=548, mean age was 21.7 years), a
recent study shows an amazing 42.7% prevalence of current WP
smoking (Azab et al., 2010). The reduced harm perception is perhaps
fueling WP use among future health professionals, as data show that
currentWPuse wasreportedby 20.6% ofmedical students in Lebanon,
23.5% of medical students in Syria, and 28.6% of medical students in
Turkey (Almerieet al., 2008;Poyrazoğlu, Şarli, Gencer, & Günay, 2010;
Saade, Warren, Jones, & Mokdad, 2009).
assessed WP use, a new picture is emerging. Ever WP use for example,
has been reported by 38% of a sample of British university students
(n=937, mean age 20 years) and 40% of a sample of French high
school students (n=920, mean age 18 years) experimented with
other tobacco products including the WP. (Jackson & Aveyard, 2008;
Slama, David-Tchouda, & Plassart, 2009). Studies in US universities
example, among a sample of 8745 students in eight colleges in the US,
29.5% reported ever WP use, and 7.2% reported current WP use
(Primack, Fertman, Rice, Adachi-Mejia, & Fine, 2010). The spread of
WP smoking among US college students, is reflected in the dramatic
rise (400% since 1999) of hookah lounges near US campuses (Martin,
2009). These trends are not confined to small-scale surveys, but are
beginning to emerge in state and national surveys. In a 2006 national
survey of Estonian students (n=13,826; age 11–15 years), WP use
was reported by 25% of boys and 16% of girls (Pärna, Usin, & Ringmets,
2008). Statewide youth tobacco use surveys in the US indicate that 7%
of 12th graders were current WP users in Arizona, while 11% of high
school students in Florida were ever users (Barnett, Curbow, Weitz,
Johnson, & Smith-Simone, 2009; Primack, Walsh, Bryce, & Eissenberg,
2009). According to the 2008 New Jersey (NJ) Youth Tobacco Survey
involving a representative sample of 3,010 high school students, 9.7%
of high school students were current waterpipe users (Jordan &
(Canadian Tobacco Use Monitoring Survey (CTUMS), 2006). The
available evidence from Australia comes from a telephone survey
conducted in 2004 and involved 1102 Arabic-speaking residents in
of participants (Carroll, Poder, & Perusco, 2008).
But perhaps the most compelling evidence about WP's growing
looking at time trends of tobacco use (1999–2008) among more than
half a million youth ages 13–15 years (involving 209 surveys in 95
countries and 5 areas). This global surveillance effort shows that while
cigarette smoking is either stable or declining, other forms of tobacco
tobacco use surveys worldwide (e.g., WP questionswill be added to the
2010 Monitoring the Future Survey). Other noted epidemiological
patterns of WP use concern its predominance among educated and
affluent youth, within a social setting, and its relation to family WP use
et al., 2007; Knishknowy & Amitai, 2005; Maziak, 2008; Maziak et al.,
2004; Maziak, Ward, Afifi Soweid, et al., 2004; Maziak, Ward, &
Eissenberg, 2004; Maziak, Ward, Afifi Soweid, & Eissenberg, 2004). So
what began as a Middle Eastern phenomenon in the 90s, has made it
quickly to the global tobacco use arena in a way that we have not
witnessed perhaps since the global cigarette epidemic (Maziak, 2010).
3. Does WP smoking pose an important public health problem?
3.1. WP's harmful potential
High quality studies of the long-term health effects of WP smoking
are still lacking. A recent systematic review of the evidence
concerning the health effects of WP smoking shows that WP smoking
more than doubles the risk of lung cancer, respiratory illness, and low
birth weight. WP smoking however, was not significantly associated
with bladder cancer, nasopharyngeal cancer, esophageal cancer, oral
dysplasia, or infertility, but the wide confidence intervals do not rule
out such associations (Akl et al., 2010). This review highlights the
Fig. 1. Actual WP (left) and schematic (right) showing main parts (Maziak, 2008).
W. Maziak / Addictive Behaviors 36 (2011) 1–5
methodological limitations of current evidence regarding WP health
effects, as well as the limitations imposed by the novelty of the WP
epidemic relative to the long latency of important smoking-related
health outcomes (e.g., lung cancer and cardiovascular disease).
Another systematic review found that the effect WP smoking on
lung function is similar to that of cigarette smoking, raising the
potential of later chronic obstructive pulmonary disease (COPD)
development as a result of WP use (Raad et al., 2010). A forecast on
WP future morbidity and mortality can be made however, based on
what we already know about WP smoking. Foremost, WP smoke
contains many of the same toxicants as cigarette smoke (e.g. those
associated with cardiovascular disease such as carbon monoxide, CO;
lung cancer such as polycyclic aromatic hydrocarbons—PAH; addic-
tion via nicotine), and these are delivered efficiently to the smoker
(Maziak, 2010; Shihadeh, 2003; Shihadeh & Saleh, 2005). For
example, analysis of smoke generated by WP users, through direct
sampling during the smoking sessions, shows that users drew a mean
of 119 L of smoke containing 150 mg of CO, 4 mg of nicotine, and
602 mg of “tar”during a single usesessionaveraging 1 h(Katurji etal.,
in press.). Measurement of users' exposure to WP-related toxicants
reveals that, relative to a single cigarette, a single WP session exposes
the smoker to 3–9 times the CO and 1.7 times the nicotine (Eissenberg
& Shihadeh, 2009; Maziak et al., 2009). Most of the CO in the
mainstream smoke of WP is likely originating from the charcoal
(Monzer, Sepetdjian, Saliba, & Shihadeh, 2008). In fact, reports of WP-
related emergency room admissions due to acute CO intoxication are
beginning to emerge (Lim, Lim, & Seow, 2009; Uyanık, Arslan, Akay,
Erçelik, & Tez, 2009), a complication that I have not come across in the
cigarette smoking literature. A lot of these harmful substances
moreover, are emitted to the surrounding air putting nonsmokers at
risk. For example, two recent studies involving human and machine-
CO, NO, as well as particulate matter), that are comparable to smoking
2–10 cigarettes for a one-hour WP session (Daher et al., 2010; Fromme
et al., 2009). Sharing the WP, a popular practice among the youth
worldwide can be associated with infectious disease risks, such as TB
(Steentoft & Andersen, 2006). And finally, evidence suggests that WP
smoking can undermine tobacco control, as it can be used as a
replacement for cigarettes among quitters, or serves as a gateway to
2008). A new study among 762 Danish youth (14–16 years) provides
the first prospective evidence that WP use predicts progression to
regular cigarette smoking among Danish youth (Jensen, Cortes,
Engholm, Kremers, & Gislum, 2010).
3.2. WP's addictive potential
In 1997 Macaron et al. demonstrated nicotine exposure in WP
usersby measuringcotininein theirurine(Macaron& Maalouf,1997).
The nicotine exposure from daily WP use is estimated to be equivalent
to smoking 10 cigarettes/day (Neergaard, Job, & Montgomery, 2007).
Other than nicotine exposure, WP smokers report known features of
dependence, such as drug-seeking behavior, use escalation with time,
and inability to quit despite repeated attempts (Maziak, Eissenberg, &
Ward, 2005). For example, in a random sample of 268 WP users in
Aleppo, 28% wanted to quit and 59% of these had made an
unsuccessful quit attempt in the past year. Belief in one's ability to
quit was inversely related to perceived dependence (Ward et al.,
2005). These observations were supported by clinical lab evidence,
where abstinent WP smokers reported many of the same withdrawal/
craving symptoms of cigarette smokers, and where these were
suppressed by subsequent WP use (Maziak et al., 2009). As
dependence becomes recognized among WP smokers, studies looking
specifically into this issue are emerging. For example, a Lebanese
group aimed to develop and validate an 11-item Lebanon WP
Dependence Scale (LWDS-11), which included four domains; ND,
negative reinforcement, psychological craving, and positive reinforce-
ment, and correlated to WP use frequency (Salameh, Waked, & Aoun,
2008). Studies at the Syrian Center for Tobacco Studies (SCTS) have
advanced a bi-dimensional concept of WP dependence; the first
reflects the effects of nicotine, and the second reflects WP's unique
social dimension and use features with more dependent smokers
increasingly showing solitary and home-based use patterns (Maziak,
Eissenberg, & Ward, 2005). For example, it was found looking at WP
use frequency – as a surrogate marker of dependence – in 268 adult
WP smokers in Aleppo (Syria), that dependent smokers engage in
behavioral adaptations to insure access to WP and manifest more
individual (vs. group) use patterns (Maziak, Ward, & Eissenberg,
2004). Case histories from WP users provide another line of evidence;
“It wentfrom something fun I did each week, to each day, to 5–6 times
a day. It became an addiction” (from www.hookahforum.com), or “I
think I'm addicted to the social aspect of hookah” (Francovich, 2009).
3.3. The need to understand WP dependence in order to develop
Smoking cessation among the youth has been hindered by the lack
of clear understanding about how the youth get hooked on tobacco.
Such understanding is needed to guide the timing, composition, and
intensity of tobacco control interventions. While information about
theinitial developmentof tobaccodependence is beginningto emerge
for cigarette smoking (e.g. DiFranza et al., 2000), knowledge to guide
WP interventions continues to be lacking. A recent Cochrane review
failed to identify a single WP cessation intervention (Maziak et al.,
2007), the development of which will require clear understanding of
salient symptoms/domains of dependence in WP users, and how they
progress in their smoking habit.
WP's unique use patterns and features (e.g. intermittent use and
prolonged sessions, preparation time, accessibility, aromatic smell,
and convivial experience of group use) will likely shape dependence
and how it is manifested in WP smokers (Maziak, Eissenberg, & Ward,
2005). For example, since the WP is not as portable and accessible as
cigarettes, WP users may engage in more intensive behavioral
adaptations to ensure access, such as carrying one's own WP to
places, and selecting cafés based on WP availability (Maziak, Ward, &
Eissenberg,2004).Other specific featuressuchasWP'ssensorystimuli
(e.g. smoke's aromatic smell) can become cues for smoking (Maziak,
Eissenberg, Rastam, et al., 2004). Moreover, the size of WP requires
deep inhalations in order to generate smoke and keep it going (puff
volume ≈500 ml, vs. ≈50 ml for cigarettes) (Breland, Kleykamp, &
Eissenberg, 2006; Maziak et al., 2009). This feature combined with a
less irritating smoke than cigarettes can lead to higher exposure to
nicotine and toxicants early on, and perhaps a faster path to
dependence. As the WP is becoming the first mod of contact with
tobacco for many youth, the balance between dependence and access
may determine which WP users are likely to initiate cigarette
4. Conclusions and policy recommendations
Taken together, the presented data not only indicate that WP
smoking has become a public health threat, but that this is perhaps
the first tobacco use method since the cigarette that is showing all
signs of a burgeoning global epidemic. They also indicate that the WP
is running its specific epidemiological course, and that its harmful and
addictive profiles are likelyto be shapedby its uniquefeaturesanduse
patterns. Despite these alarming trends most national and interna-
tional tobacco control strategies (e.g. clean indoor air policies, pro-
hibition of advertisement and sales to minors, large or graphic
warning labels, and taxation), including the Framework Convention
on Tobacco Control (FCTC), still do not clearly address this tobaccouse
W. Maziak / Addictive Behaviors 36 (2011) 1–5
method (Maziak, 2008). Furthermore, the WP is not currently
regulated (e.g. by the US Food and Drug Administration, or the
Canadian Food Inspection Agency), and the content and packaging of
WP tobacco, or other accessories, sold on the market are not
standardized (Gatrad et al., 2007; Knishknowy & Amitai, 2005;
Maziak, 2008; World Health Organization, 2005). For example, new
evidence shows that WP charcoal, as sold off the shelf, already con-
tains high levels of PAH that varies systematically by brand, indicating
a room for regulation (Sepetdjian et al., 2010). On the other hand, in
some parts of the world (e.g. US), WP venues can be benefiting from
smoking bans in restaurants and bars, because they can be exempted
under the “retail tobacco establishment” classification (American
Lung Association, 2009; Devon, 2010; Noonan, 2010). In addition,
many WP users are driven by a misperception of reduced harm/
addictiveness, which can be re-enforced by deceptive descriptors that
appear on WP tobacco packages (e.g., “contains 0% tar and 0.5% or
0.05% nicotine”) or accessories such as the charcoal (e.g. “smokeless
and odorless”, “free of chemicals”, “100% natural”) (Khalil, Heath,
Nakkash, & Afifi, 2009; Nakkash & Khalil, 2010; Wilson et al., 2009).
All these descriptors aim to create an impression of a healthy product,
and should be countered by appropriate packaging and advertisement
policies. In contrast, health warnings, written or graphic, need not
only to follow the FCTC size requirements (e.g. at least 30% of the
package), but be mindful as well of the complexity of WP as a tobacco
use method. For example, WP users in the common café/restaurant
social setting are not exposed to health warnings on the WP tobacco
package because they are served the product already packed with
tobacco. Accordingly, policy initiatives such as health warnings and
bans on advertisement/deceptive descriptors should accommodate
the multi-component nature of this tobaccousemethod as body parts,
hose, charcoal, tobacco mixture, filters, mouthpieces, and aluminum
foil can be sold separately. Such measures moreover, need to adapt to
the fact that most hookah promotion and sales, at least in western
societies, are done through the internet (Cobb et al., 2010), and at
times are concealed under scientific disguise (e.g. the Sacred Narghile
Given WP's global reach, its potential to hook young people on
nicotine, to replace cigarettes among quitters, and to harm smokers
and nonsmokers alike, WP smoking threat to global public health
need not be overemphasized. Understanding the WP's unique
features and how these influence users as they progress in their
smoking habit, as well as the environment that supports WP use will
be essential for the development of treatment and policy interven-
tions to curb the global WP epidemic.
Role of Funding Sources
Funding for this review is provided by a grant from the National Institute on Drug
Abuse (R01 DA024876).
Maziak W wrote the review.
Conflict of Interest
The author declares that he has no conflicts of interest related to this article.
Akl, E. A., Gaddam, S., Gunukula, S. K., Honeine, R., Jaoude, P. A., & Irani, J. (2010). The
effects of waterpipe tobacco smoking on health outcomes: A systematic review.
International Journal of Epidemiology, 39(3), 834−857.
Almerie, M.,Matar, H.,Salam, M.,Morad, A., Abdelal, M.,& Maziak, W.(2008). Cigarettes
& waterpipe smoking among medical students in Syria: A cross-sectional study. The
International Journal of Tuberculosis and Lung Disease, 12(9), 1085−1091.
American Lung Association, (2009). Tobacco Policy Trend Alert AN EMERGING
DEADLY TREND:WATERPIPE TOBACCO USE. (www.slati.lungusa.org/alerts/Trend
Anjum, Q., Ahmed, F., & Ashfaq, T. (2008). Knowledge, attitude and perception of water
pipe smoking (Shisha) among adolescents aged 14–19 years. Journal Of Pakistan
Medical Association, 58(6), 312−317.
Asfar, T., Weg, M., Maziak, W., Hammal, F., Eissenberg, T., & Ward, K. (2008). Outcomes
and adherence in Syria's first smoking cessation trial. American Journal of Health
Behavior, 32, 146−156.
Azab, M., Khabour, O. F., Alkaraki, A. K., Eissenberg, T., Alzoubi, K. H., & Primack, B. A.
(2010). Water pipe tobacco smoking among university students in Jordan. Nicotine
& Tobacco Research, 12(6), 606−612.
Barnett, T., Curbow, B., Weitz, J., Johnson, T., & Smith-Simone, S. (2009). Water pipe
tobacco smoking among middle and high school students. American Journal of
Public Health, 99(11), 2014−2019.
Breland, A. B., Kleykamp, B. A., & Eissenberg, T. (2006). Clinical laboratory evaluation of
potential reduced exposure products for smokers. Nicotine & Tobacco Research, 8,
Canadian Tobacco Use Monitoring Survey (CTUMS), (2006).
Carroll, T., Poder, N., & Perusco, A. (2008). Is concern about waterpipe tobacco smoking
warranted? Australian and New Zealand Journal of Public Health, 32(2), 181−182.
Cobb, C., Ward, K., Maziak, W., Shihadeh, A., & Eissenberg, T. (2010). Waterpipe tobacco
smoking: An emerging health crisis in the United States. American Journal of Health
Behavior, 34(3), 275−285.
Daher, N., Saleh, R., Jaroudi, E., Sheheitli, H., Badr, T., Sepetdjian, E., et al. (2010).
Comparison of carcinogen, carbon monoxide, and ultrafine particle emissions from
narghile waterpipe and cigarette smoking: Sidestream smoke measurements and
assessment of second-hand smoke emission factors. Atmospheric Environment, 44(1),
Devon, N. (2010). Exemptions for hookah bars in clean indoor air legislation: A public
health concern. Public Health Nursing, 27(1), 49−53.
DiFranza, J., Rigotti, N., McNeill, A., Ockene, J., Savageau, J., Cyr, D. S., et al. (2000). Initial
symptoms of nicotine dependence in adolescents. Tobacco Control, 9(3), 313−319.
Eissenberg, T., & Shihadeh, A. (2009). Waterpipe tobacco and cigarette smoking: Direct
comparison of toxicant exposure. American Journal of Preventive Medicine, 37(6),
Francovich, E. (2009). Hooked on hookah. : The NIC Sentinel (http://media.www.
Fromme, H. D. S., Heitmann, D., Dressel, H., Diemer, J., Schulz, T., Jörres, R. A., et al.
(2009). Indoor air contamination during a waterpipe (narghile) smoking session.
Food and Chemical Toxicology, 47(7), 1636−1641.
Gatrad, R., Gatrad, A., & Sheikh, A. (2007). Hookah smoking. British Medical Journal, 335
Hammal, F., Mock, J., Ward, K. D., Eissenberg, T., & Maziak, W. (2008). A pleasure among
friends: How narghile (waterpipe) smoking differs from cigarette smoking in Syria.
Tobacco Control, 17(2), e3.
Jackson, D., & Aveyard, P. (2008). Waterpipe smoking in students: Prevalence, risk
factors, symptoms of addiction, and smoke intake. Evidence from one British
university. BMC Public Health, 8, 174.
Jawaid, A., Zafar, A., Rehman, T., Nazir, M., Ghafoor, Z., Afzal, O., et al. (2008).
Knowledge, attitudes and practice of university students regarding waterpipe
smoking in Pakistan. The International Journal of Tuberculosis and Lung Disease, 12
Jensen, P., Cortes, R., Engholm, G., Kremers, S., & Gislum, M. (2010). Waterpipe use
predicts progression to regular cigarette smoking among Danish youth. Substance
Use & Misuse, 45(7–8), 1245−1261.
Jordan, H. M., & Delnevo, C. D. (2010). Emerging tobacco products: Hookah use among
New Jersey youth. Preventive Medicine (Electronic publication ahead of print).
Katurji M, Daher N, Sheheitli H, Saleh R, & Shihadeh A, (in press.). Direct measurement
of toxicants inhaled by waterpipe users in the natural environment using a real-
time in-situ smoke sampling (RINS) technique. Inhalation Toxicology.
Khalil, J., Heath, R. L., Nakkash, R. T., & Afifi, R. A. (2009). The tobacco health nexus?
Health messages in narghile advertisements. Tobacco Control, 18(5), 420−421.
Knishknowy, B., & Amitai, Y. (2005). Water-pipe (narghile) smoking: An emerging
health risk behavior. Pediatrics, 116(1), e113−e119.
Lim, B., Lim, G., & Seow, E. (2009). Case of carbon monoxide poisoning after smoking
shisha. International Journal of Emergency Medicine, 2(2), 121−122.
Macaron, C. M. Z., & Maalouf, M. T. (1997). Urinary cotinine in narguila or chicha
tobacco smokers. Le Journal Médical Libanais, 45(19–20).
Martin, J. (2009). Booming hookah biz links China, Iran, Egypt- and Texas. CNN Money
Maziak, W. (2008). The waterpipe: Time for action. Addiction, 11, 1763−1767.
Maziak, W. (2010). The waterpipe—A global epidemic or a passing fad. International
Journal of Epidemiology, 39(3), 857−859.
Maziak, W., Eissenberg, T., Rastam, S., Hammal, F., Asfar, T., Bachir, M., et al. (2004).
Beliefs and attitudes related to narghile (waterpipe) smoking among university
students in Syria. Annals of Epidemiology, 14(9), 646−654.
Maziak, W., Rastam, S., Ibrahim, I., Ward, K., Shihadeh, A., & Eissenberg, T. (2009). CO
exposure, puff topography, and subjective effects in waterpipe tobacco smokers.
Nicotine & Tobacco Research, 11(7), 806−811.
Maziak, W., Eissenberg, T., & Ward, K. D. (2005). Patterns of waterpipe use and
dependence: Implications for intervention development. Pharmacology Biochem-
istry and Behavior, 80(1), 173−179.
Maziak, W., Ward, K. D., Afifi Soweid, R. A., & Eissenberg, T. (2004). Tobacco smoking
using a waterpipe: A re-emerging strain in a global epidemic. Tobacco Control, 13
Maziak, W., Ward, K. D., & Eissenberg, T. (2004). Factors related to frequency of narghile
(waterpipe) use: The first insights on tobacco dependence in narghile users. Drug
and Alcohol Dependence, 76, 101−106.
Maziak, W., Ward, K. D., & Eissenberg, T. (2007). Interventions for waterpipe smoking
cessation. Cochrane Database of Systematic Reviews, 4, CD005549.
W. Maziak / Addictive Behaviors 36 (2011) 1–5
Monzer, B., Sepetdjian, E., Saliba, N., & Shihadeh, A. (2008). Charcoal emissions as a Download full-text
source of CO and carcinogenic PAH in mainstream narghile waterpipe smoke. Food
and Chemical Toxicology, 46(9), 2991−2995.
Nakkash, R., & Khalil, J. (2010). Health warning labelling practices on narghile (shisha,
hookah) waterpipe tobacco products and related accessories. Tobacco Control, 19
Neergaard, J. S. P., Job, J., & Montgomery, S. (2007). Waterpipe smoking and nicotine
exposure: A review of the current evidence. Nicotine & Tobacco Research, 9(10),
Noonan, D. (2010). Exemptions for hookah bars in clean indoor air legislation: A public
health concern. Public Health Nursing, 27(1), 49−53.
Pärna, K., Usin, J., & Ringmets, I. (2008). Cigarette and waterpipe smoking among
adolescents in Estonia: HBSC survey results, 1994–2006. BMC Public Health, 8,
Poyrazoğlu, S., Şarli, Ş., Gencer, Z., & Günay, O. (2010). Waterpipe (narghile) smoking
among medical and non-medical university students in Turkey. Upsala Journal of
Medical Sciences, 115(3), 210−216.
Primack, B., Fertman, C., Rice, K., Adachi-Mejia, A., & Fine, M. (2010). Waterpipe and
cigarette smoking among college athletes in the United States. The Journal of
Adolescent Health, 46(1), 45−51.
Primack, B., Walsh, M., Bryce, C., & Eissenberg, T. (2009). Water-pipe tobacco smoking
among middle and high school students in Arizona. Pediatrics, 123(2), e282−e288.
Raad, D., Gaddam, S., Schunemann, H. J., Irani, J., Abou Jaoude, P., Honeine, R., et al.
(2010). Effects of waterpipe tobacco smoking on lung function: A systematic
review and meta-analysis.Chest Jul 29. [Epub ahead of print].
Saade, G., Warren, C., Jones, N., & Mokdad, A. (2009). Tobacco use and cessation
counseling among health professional students: Lebanon Global Health Professions
Student Survey. Le Journal Médical Libanais, 57(4), 243−247.
Salameh, P., Waked, M., & Aoun, Z. (2008). Waterpipe smoking: Construction and
validation of the Lebanon Waterpipe Dependence Scale (LWDS-11). Nicotine &
Tobacco Research, 10(1), 149−158.
Sepetdjian, E., Saliba, N., & Shihadeh, A. (2010). Carcinogenic PAH in waterpipe charcoal
products. Food and Chemical Toxicology (Electronic publication ahead of print).
Shihadeh, A. (2003). Investigation of mainstream smoke aerosol of the argileh water
pipe. Food and Chemical Toxicology, 41(1), 143−152.
Shihadeh, A., & Saleh, R. (2005). Polycyclic aromatic hydrocarbons, carbon monoxide,
“tar”, and nicotine in the mainstream smoke aerosol of the narghile water pipe.
Food and Chemical Toxicology, 43(5), 655−661.
Slama, K., David-Tchouda, S., & Plassart, J. (2009). Tobacco consumption among young
adults in the two French departments of Savoie in 2008. Revue d'Épidémiologie et de
Santé Publique, 57(4), 299−304.
Steentoft, J. W. J., & Andersen, J. R. (2006). Tuberculosis and water pipes as source of
infection. Ugeskrift for Laeger, 168(9), 904−907.
carboxyhemoglobin levels. The Journal of Emergency Medicine Epub ahead of print].
Ward, K., Hammal, F.,VanderWeg,M., Eissenberg, T., Asfar,T.,Rastam, S., etal. (2005). Are
waterpipe users interested in quitting? Nicotine & Tobacco Research, 7, 149−156.
Warren, C. W., Lea, V., Lee, J., Jones, N. R., Asma, S., & McKenna, M. (2009). Change in
tobacco use among 13–15 year olds between 1999 and 2008: Findings from the
Global Youth Tobacco Survey. Global Health Promotion, 16(2_suppl), 38−90.
Wilson, N., Weerasekera, D., Peace, J., Edwards, R., Thomson, G., & Devlin, M. (2009).
Misperceptions of “light” cigarettes abound: National survey data. BMC Public
Health, 9(1), 126.
World Health Organization (WHO). (2005). Waterpipe tobacco smoking: Health
effects, research needs and recommended actions by regulators. Geneva,
W. Maziak / Addictive Behaviors 36 (2011) 1–5