ArticlePDF Available

Use & Misuse of Water-filtered Tobacco Smoking Pipes in the World. Consequences for Public Health, Research & Research Ethics

Authors:

Abstract and Figures

BACKGROUND: The traditional definition of an “epidemic” has been revisited by antismoking researchers. After 400 years, Doctors would have realized that one aspect of an ancient cultural daily practice of Asian and African societies was in fact a “global “epidemic””. This needed further investigation particularly if one keeps in his mind the health aspects surrounding barbecues. METHOD: Here, up-to-date biomedical results are dialectically confronted with anthropological findings, hence in real life, in order to highlight the extent of the global confusion: from the new definition of an “epidemic” and “prevalence” to the myth of “nicotine “addiction”” and other themes in relation to water filtered tobacco smoking pipes (WFTSPs). RESULTS: We found that over the last decade, many publications, -particularly reviews, “meta-analyses” and “systematic reviews”- on (WFTSPs), have actually contributed to fuelling the greatest mix-up ever witnessed in biomedical research. One main reason for such a situation has been the absolute lack of critical analysis of the available literature and the uncritical use of citations (one seriously flawed review has been cited up to 200 times). Another main reason has been to take as granted a biased smoking robot designed at the US American of Beirut whose measured yields of toxic chemicals may differ dozens of times from others' based on the same “protocol”. We also found that, for more than one decade, two other main methodological problems are: 1) the long-lived unwillingness to distinguish between use and misuse; 2) the consistent unethical rejection of biomedical negative results which, interestingly, are quantitatively and qualitatively much more instructive than the positive ones. CONCLUSION: the great majority of WFTSP toxicity studies have actually measured, voluntarily or not, their misuse aspects, not the use in itself. This is in contradiction with both the harm reduction and public health doctrines. The publication of negative results should be encouraged instead of being stifled. KEYWORDS: Electronic cigarette, harm reduction, hookah, narghile, public health,shisha, smoking, tobacco [NOTE: This article also offers a thorough response to all issues raised in the March 2015 (vol. 24, suppl. 1) issue of the "Tobacco Control" antismoking journal titled: "Waterpipe Tobacco Smoking: A Global Epidemic]
Content may be subject to copyright.
Send Orders for Reprints to reprints@benthamscience.ae
The Open Medicinal Chemistry Journal, 2015, 9, 1-12 1
1874-1045/15 2015 Bentham Open
Open Access
Use & Misuse of Water-filtered Tobacco Smoking Pipes in the World.
Consequences for Public Health, Research & Research Ethics
Kamal Chaouachi
*
DIU Tabacologie, Université Paris XI, France
Abstract: Background: The traditional definition of an “epidemic” has been revisited by antismoking researchers. After
400 years, Doctors would have realized
that one aspect of an ancient cultural daily practice of Asian and African societies
was in fact aglobal “epidemic””. This needed further investigation particularly if one keeps in his mind the health as-
pects surrounding barbecues. Method
: Here, up-to-date biomedical results are dialectically confronted with anthropologi-
cal findings, hence in real life, in order to highlight the extent of the global confusion: from the new definition of an “epi-
demic” and “prevalence” to the myth of nicotine “addiction”” and other themes in relation to water filtered tobacco
smoking pipes (WFTSPs). Results
: We found that over the last decade, many publications, -particularly reviews, “meta-
analyses” and “systematic reviews”- on (WFTSPs), have actually contributed to fuelling the greatest mix-up ever wit-
nessed in biomedical research. One main reason for such a situation has been the absolute lack of critical analysis of the
available literature and the uncritical use of citations (one seriously flawed review has been cited up to 200 times). An-
other main reason has been to take as granted a biased smoking robot designed at the US American of Beirut whose
measured yields of toxic chemicals may differ dozens of times from others' based on the same “protocol”. We also found
that, for more than one decade, two other main methodological problems are: 1) the long-lived unwillingness to distin-
guish between use and misuse; 2) the consistent unethical rejection of biomedical negative results which, interestingly, are
quantitatively and qualitatively much more instructive than the positive ones. Conclusion
: the great majority of WFTSP
toxicity studies have actually measured, voluntarily or not, their misuse aspects, not the use in itself. This is in contradic-
tion with both the harm reduction and public health doctrines. The publication of negative results should be encouraged
instead of being stifled.
Keywords: Electronic cigarette, harm reduction, hookah, narghile, public health,shisha, smoking, tobacco.
1. INTRODUCTION
This is likely the first time in the annals of medicine that
a several century-old cultural invention, being simultane-
ously a peculiar trait of many African and Asian societies, is
described in the biomedical literature of the last decade as an
“epidemic” and even a global one [1]. From an epistemo-
logical standpoint, it is worth stressing that in a not so re-
mote past, both anthropological and biomedical research
findings about the domesticated health aspects of the practice
used to agree with each other. However, a sudden change has
occurred in 2002. The main reason is the sudden adoption,
from that year onwards, of a reductionist approach whereby
the highly complex socio-cultural matrix of a human daily
practice, namely the use and misuse of water filtered tobacco
smoking pipes (WFTSPs) across the world, has virtually
been overlooked. Interestingly, a recent scholarly article de-
nounces for the first time the existence of “biomedical reduc-
tionism in tobacco control” (sic) [2].
On one hand, a so-called laboratory “model” of the corre-
sponding human practice was designed at the US-AUB (US
American University of Beirut). It is actually a mere smoking
robot whose relevance has been widely, although blindly, ac-
cepted by many as “standardised” [1]. On the other hand,
*Address correspondence to this author at the DIU Tabacologie, Universi
Paris XI, 63 avenue Gabriel Peri, 94276 Le Kremlin-Bicêtre, France;
Tel: 33 1 4959 6617; Fax: 33 1 5839 3695; E-mail: kamcha@gmail.com
all WFTSPs, in spite of their well known material and socio-
cultural diversity, have been arbitrarily lumped together un-
der a same umbrella. A neologism was invented for this pur-
pose: ««waterpipe»» in one word. From the outset, we have
stressed that such a methodological move amounted to a
form of unscientific reductionism whose direct outcome is a
global confusion regarding concepts and objects alike. What
has also gone unnoticed so far is that a clear line has never
been drawn between the actual use of these pipes and their
misuse. In many instances, such a line reflects the classical
distinction between traditional vs. modern use. If one com-
pares with the usual approach when it comes to other aspects
of everyday’s life -from the (mis) use of knives to the eating
of grilled vegetables or meat in traditional (or modern) de-
vices like barbecues- one may be tempted to conclude to
double standards. The latter example is even more relevant
that it also entails the generation of smoke and the corre-
sponding misuse should also raise health concerns regarding
its potential toxicity [3, 4]. Unfortunately, it seems here that
when things relate to tobacco use and abuse, human passions
or economic interests take over the scientific method.
Overlooking the striking diversity of WFTSPs represents
a serious ethical and methodological error since all water
pipes (in two words) of the world have almost nothing in
common but that ««waterpipe»» name arbitrarily imposed
one decade ago [5]. From there, ««waterpipe»»-labelled
clinical studies, or those carried out in a “real” “natural” en-
vironment, have generally mixed up different products used
2 The Open Medicinal Chemistry Journal, 2015, Volume 9 Kamal Chaouachi
by the smokers: e.g., plain tobacco of the tumbak, ajamy or
tutun type with the popular flavoured moassel (tabamel), etc
(See Figs. 1, 2, 3). Yet, the smoke chemistry of both (or
more) types is completely different in each case and results
in different health effects. What did also exacerbate the
global confusion, is that the corresponding researchers, in an
endeavour to demonstrate that the claimed health effects
(e.g., on lung function) are supported by other studies, often
blindly refer to the above mentioned US-AUB' smoking ro-
bot. Yet, they do not realise, or simply wish to ignore, how
biased are the corresponding procedures which led to the
imposition of the puffing machine in question [6, 7]. Indeed,
it was recently stressed how two smoking machines, in two
different laboratories from two different countries (Germany
and Lebanon) could produce acrolein and benzo[a]pyrene
levels 66 and 20 times different, respectively, in each case
[5]. Yet, the two robots were set with similar (biased) pa-
rameters: notably an exaggerated inter-puff time interval of
17s/20s; the charcoal (non-natural) literally burning the fla-
voured smoking mixture instead of just heating it (because of
its arbitrarily fixed position atop the bowl, for one full hour).
More recently, such a hazardous chemical as phenol was
quantified at levels 18 times lower than those previously
produced by the US-AUB's robot (3.21g vs. 58.03g) [8].
Interestingly, a common cigarette, used as a reference in
similar experiments, generates (in only a few minutes) two
times the phenol level produced by a shisha (over one full
hour)… If one also bears in mind that while a common ciga-
rette smoker may consume 20 units a day, and that shisha is
generally smoked, according to recent epidemiological data,
1 to 3 times per week (i.e. a frequency of 0.14 to 0.43 pipe
per day), then the abuse of toxicity comparisons between
cigarettes and WFTSPs is blindingly obvious.
Fig. (1). Tumbak (ajamy), a classical” product in Asia and Africa. It
is close to the one used by the volunteers in Mohammad et al.'
study on their lung function [18]. Main characteristic: direct contact
between the charcoal and the tobacco plant.
The question that arises is: how have researchers been
able to trust so easily similar instruments (robots) and then
feel entitled to warn against alarming levels of hazardous
chemicals supposedly present in “««waterpipe»» smoke”?
The answer is that there is a clear agenda behind such an
“activism”(sic) [9]. The so-called scientific “evidence” is nec-
essary for ongoing legislation in dire straits because WFTSP
now represents, according to antismoking researchers them-
selves, a major obstacle towards a “tobacco-free word”. For
them, a “tobacco “control” policy” undoubtedly represents “an
effective step towards eradication”(sic) [9, 10].
Fig. (2). Moassel (tabamel), a mixed product between tumbak and
jurak (see reference book)[1]. The chemistry of its smoke is com-
pletely different from that of tumbak whose study has been pre-
vented by the use of the unscientific confusion-fuelling neologism
««waterpipe»». Main characteristic: no direct contact between the
charcoal and the smoking mixture.
Not only has the definition of an “epidemic” been revis-
ited, as pointed out before, but also that of prevalence and
psycho-pharmacological addiction as we will see further
down. The answer to how such a global confusion, never
witnessed before and elsewhere in the biomedical field [5],
has been possible, certainly deserves a tentative answer; per-
haps of a sociological nature [2]. In fact and with the benefit
of hindsight, we can now state that a great number of re-
searchers working on the hot issue of WFTSPs have got a
poor grasp of the basics of tobacco science, not to mention of
the everyday's life material culture of Asian and African so-
cieties. To make things worse, they often lack both skills in
the same time even when some of them are physicians or
biochemists native of those regions [1]. Yet, cumulated
negative results (i.e. findings showing that WFTSPs are not
associated with all the new alarmist risks) published in peer-
reviewed journals over the past decades, and more recent
ones, are numerous and exceeding, in quality at least, the
purported positive results, in spite of a now permanent sti-
fling of debate [11-18]. ««Waterpipe»» antismoking teams
always find a way round to avoid mentioning negative re-
sults (e.g. during the “selection” of bibliographical refer-
ences when preparing “reviews”, “systematic” or not, and
other “meta-analyses”. They may also be embarrassed when
antismoking researchers themselves come up with such
negative results as this happened with a toxicity study from
the United Kingdom involving a smoking robot similar to
the US-AUB one. Given that the results openly collide to-
tally with those widely advertised by the US-AUB, the study
has simply sunk into oblivion. Their authors, apparently em-
barrassed, downplayed the importance of their own findings
[19].
Interestingly, in the recent debate over electronic ciga-
rettes, “tobacco harm reduction” advocates, supposed to
benefit from a large experience of exposing the prevalent
shoddy science of “tobacco “control”” research, have echoed
in their turn, and without the least critique, the claims against
flavoured shisha. Amazingly, they did not realise that the
Use & Misuse of Water-filtered Tobacco Smoking Pipes The Open Medicinal Chemistry Journal, 2015, Volume 9 3
smoke of the latter (when prepared correctly, not according
to the US-AUB “method”) is much more similar to the va-
pour of E-cigarettes than the smoke of regular ones [20].
2. USE AND MISUSE OF WATER FILTERED TO-
BACCO SMOKING PIPES (WFTSPs)
It has been already made clear that the biochemical and
anthropological aspects of both water filtered and cigarette
smoking (particularly regarding the so-called second-hand
smoke) are completely different from each other [20, 21].
For many years and in tune with a global prohibitionist
agenda –as implicitly reflected in the clauses of the FCTC
(“Framework Convention for “Tobacco Control”) [10, 22],
the mainstream media have, in an uncritical way, echoed
««waterpipe»» experts' claims that the health effects of a
common shisha smoking session are 100, 200 (and even
more…) worst than those caused by regular cigarettes [23].
Further to relevant necessary critiques [5, 11, 20, 24], the
new motto has suddenly become that both smokes “have
[“only”] similar negative effects”… For the follower of such
a mind-boggling “public health” issue, not only has the tox-
icity ratio suddenly been divided by a factor of at least
100…, but such a new statement remains as false and unsci-
entific as the previous one…. Instead of a public apology,
««waterpipe»» antismoking researchers themselves are now
advising to each other not to compare anymore hookahs with
cigarettes in such an arithmetic way [25]. However, the new
“equivalence” (1:1 instead of 1:100) still represents a gross
exaggeration because the chemistry of shisha smoke is so
different and its matrix so much less complex than the one
generated by a regular cigarette: dozens of times less concen-
trated, sometimes by two orders of magnitude. Indeed, only
some 150 chemicals have been officially identified so far vs.
5,000 for cigarette [20]. Further to our one-decade long re-
lentless emphasis on this point [20], a few antismoking ex-
perts now begin to openly admit the fact and echo it in their
turn [8, 26]. For example, nitrosamines are likely the most
hazardous chemicals present in tar. Interestingly, and when
compared with cigarette smoke, these products are consis-
tently found (when they actually reach detection levels) in
much lower concentrations in human hookah smokers, even
when the water inside the tank has not been changed as is
often the case (voluntarily or not) in a long series of biased
studies carried out by antismoking teams [5, 27-29]. Most of
the time, what has been actually measured in experimental
toxicity or clinical studies, is either the result of: blatant bi-
ases (e.g. smoking machines cited as “realistically” mimick-
ing the complex use of WFTSPs [5-7]); heavy use as in some
Egyptian studies (in which some patients may regularly sit
for 5 pipes and more a day, a smoking pattern barely ob-
served outside Asia and Africa [1]); misuse (by inexperi-
enced users still unfamiliar with a four-century old technique
[1]); and/or poor hygiene [5]. Perhaps would it be more cor-
rect, for the latter cases, to sayabuse” instead of “misuse”,
one relevant comparison being the consumption of alcohol.
If water (in the tank) had “no filtering effect”, according
to antismoking public claims, why has been the “detail” of
changing it after each smoking session “overlooked” in so
many studies? To top it all, the subjects of a recent study in
California (USA) were even compelled to smoke a minimum
of two pipes in the morning [27]... Furthermore, in spite of
the poorly convincing results (the toxicity of hookah smok-
ing proved to be far less important in terms of quantified
metabolites of known carcinogens), the authors generally do
not refrain from hyping their findings in the mainstream me-
dia [27]. Confusion in this field has assuredly reached un-
precedented, unexpected degrees. A team from the US-AUB,
supposed to lead ««waterpipe»» research on a global level,
even believed tar can be found in the tobacco plant itself
[7, 30], whereas the basis of tobacco science (tobaccology)
makes it quite clear to first year medical students that such a
chemical compound only appears once the cigarette has been
lighted, never before. In these conditions, it is apparently
easy to lead astray the general public and lawmakers when
official research is carried out and published in the biomedi-
cal press in this way including reports published by the
WHO [5, 9-10, 20, 22-24]. Researchers on drug use know
well how a word like “eradication” (used in a recent article
[10]) may be interpreted and tapped. When the targeted pub-
lic does not distinguish between shisha tar and cigarette tar
(the former being much less toxic for being produced at tem-
peratures hundreds of degrees Celsius below those at the tip
of a cigarette), it is clear that it can be easily deceived. From
there, nonsense (like: “the inhaled smoke from a one-hour
waterpipe session contains as much tar as up to 600 ciga-
rettes” [31]) stated by one of the authors of the WHO flawed
report [24], can be published with no reaction.
WFTSP misuse often results from the lack, or poorness,
of ventilation [1, 20]. All cases of shisha-induced Carbon
Monoxide poisoning recently reported in the literature are a
direct result of the lack of public health warnings (against
smoking in such places as ill-ventilated bedrooms and the
like), rather than because the pipes themselves would consis-
tently or inherently cause CO intoxication. The comparison
with barbecues should be kept in mind here. Less and less
people get CO-poisoned when using barbecues simply be-
cause appropriate public health warnings about their use are
widespread. Another relevant comparative example here is
the electronic cigarette because public health officials have
recently reported an elevated numbers of telephone calls to
poison centres, likely due to the misuse of these new prod-
ucts [32]. One ethical question here is: why do shisha users
(at least outside Africa and Asia where the practice is well
domesticated) are not entitled to benefit from similar warn-
ings? Furthermore, one often silenced aspect of WFTSP use
is that such pipes are smoked (at least under their traditional
form) much like cigars. Now, the latter are well known for
producing large quantities of CO. Research early established
that cigar inhalers had markedly elevated concentrations of
carboxyhaemoglobin (13.8% and 11.8% in primary and sec-
ondary inhalers, respectively) [33]. Cigar users know that
ventilation is important [20-34]. Interestingly, a relevant
study in Jordan involving a wide sample (14,310 subjects),
showed that the increase of arterial blood pressure and heart
rate among exclusive shisha smokers remained quite modest
(92.57 to 92.62 and 76.40 to 76.81, respectively [14].
The same goes for most hazardous chemicals (heavy
metals, etc.) which are sometimes found in users’ body flu-
ids. Given that the levels of these products in the very moas-
sel/tabamel (the gooey smoking mixture in shisha) are much
less elevated than in the tobacco rod of cigarettes, it appears
that their presence in body fluids, when it occurs, is likely
4 The Open Medicinal Chemistry Journal, 2015, Volume 9 Kamal Chaouachi
Fig. (3). Jurak, also a “classical” product in Asia and Africa. It is close to the one used by the volunteers in Sajid et al.'s study [11]. Painting
depicting a Tunisian scene.
due to: the misuse of the thermal screen (aluminium, com-
monly of cookware quality) separating the heating source
from the moassel; the metal coating of the pipes (particularly
the bowl) and/or; the charcoal. As with ventilation, any pub-
lic health campaign worthy of this name should have actu-
ally warned users against this problem, for more than one
decade now [1, 16, 20]. Such harm reduction based recom-
mendations also apply to benzene produced by the charcoal
as in barbecues [3-4, 8, 35]. Instead of exclusively hyping
the risks of inhaling benzene, WFTSP users could simply be
invited as follows: “if you wish to smoke hookah, please
avoid ill-ventilated places” [1, 20]. If, as the authors of an
alarmist study state “there is no safe level of exposure to
benzene” and even suggest to “revent” (does this also mean
“ban”?) hookah smoking [35], then should not automobiles
and barbecues, known to emit much larger amounts of that
chemical, be also targeted by the same warnings? Olsson &
Petersson found that above charcoal for grilling, benzene
concentration exceeded 10 mg m-3 at a 5% carbon dioxide
level [3]. In sum, what most WFTSP toxicity studies gener-
ally have shown so far to potential users is, at best, “how not
to smoke” rather than the poisons they actually inhale [5].
3. LAB TOXICITY TESTS CONSISTENTLY CON-
TRADICT ACTUAL HEALTH EFFECTS ON HU-
MANS
As previously stated in the literature, the so-called great
health hazards taken as granted by some researchers have
been deducted from a series of biased experimental studies
chiefly based on smoking machines [5-7, 20, 24]. In these
conditions, it is not surprising to see that recent in-vitro stud-
ies, and others carried out in a “real”-environment or on real
human smokers (not robots), are generally contradicted by
independent studies led on humans [5, 14-15, 27, 35]. For
instance, independent researchers in Tunisia recently found
that the lung function of exclusive heavy (users of a strong
jurak-like product) (See Fig. 3)
was much less affected than
that of chronic exclusive cigarette smokers. Although sur-
rounded with some unclear areas –whereby subjects had
been likely exposed to both types of smoke–, a Syrian inde-
pendent group also came to not dissimilar conclusions [17-
18]. Amazingly, such studies were not cited by Lebanese
researchers who would select only “positive” although bi-
ased already criticised results [38-40].
We have highlighted before how the yields of toxic
chemicals (acrolein, phenol, benzo[a]pyrene, etc.) produced
by different teams using a similar smoking robot were totally
colliding between each other. For instance, Apsley et al. in
the UK reported mainstream smoke CO levels ranging from
800 to 1000 ppm “suggesting a typical CO yield of 30mg per
smoking session. They emphasised that they were unable to
detect (L.O.D. < 0.02 μg) many of the PAHs (polycyclic
aromatic hydrocarbons). The same for most metals [19]. By
contrast, and just to take Cobalt as an example, the German
team, in its turn, suggests levels 400% greater than those
measured on the US-AUB robot [8].
Other researchers have analysed heavy metals present in
the moassel itself. For instance, Saadawi et al. stresses that
“the average mass of the more toxic elements (As, Cd, Cr
and Pb) present in a hookah smoking portion of about 15 g,
is smaller than that contained in a normal cigarette” [36].
This is in agreement with another detailed analysis of trace
elements led by Khater et al. and previous ones in the Mid-
dle East [16, 37] (See Fig. 6).
For benzene, in the worst case and supposing the levels
had some reality (absurd hypothesis), the German
antismoking team recently found 271g [8]. This represents,
without taking any methodological precaution, the “equiva-
lent” of the volatile compound produced by six 2R4REF
cigarettes (43.4g); bearing in mind, however, the earlier
stressed shisha average frequency of 0.14 to 0.43 pipe per
day.
The trend to highlight “positive results” and overlook
negative results is patent [5, 24]. Before year 2002 (inception
of ««waterpipe»» antismoking research), almost all research
Use & Misuse of Water-filtered Tobacco Smoking Pipes The Open Medicinal Chemistry Journal, 2015, Volume 9 5
was of the latter type. Interestingly, it has been conducted by
the pioneers and greatest names of independent (from both
the pharmaceutical and tobacco industries) tobacco science
like Ernst Wynder, Dietrich Hoffmann, etc. [11].
Independently obtained data generally, and consistently,
contradict the widely advertised laboratory toxicity levels
produced by the US-AUB smoking robot. When they do not,
this is generally due to confusion factors or blatant flaws as
not changing the water [5, 27-29].
To top it all, the levels of toxic chemicals, most of the
time, and for most of them, remain much lower than those
related to cigarette use [8, 19, 28, 29]… Because of the
prevalent prohibition (“eradication” (sic)) paradigm [10], and
the related world FCTC agenda [10, 22], many researchers
who come up with negative results feel somewhat embar-
rassed and systematically tend to downplay them (a psycho-
sociological process also known as cognitive dissonance). A
few years back, at an international anti-tobacco conference, a
study (not yet published by the time of the event) on a series
of toxic carcinogenic chemicals was announced. Unsurpris-
ingly, the levels were not higher than among cigarette smok-
ers and, most of the time, not very different from controls.
Even the level of NNAL (4-(methylnitrosamino)-1-(3-
pyridyl)-1-butanol), metabolite of the potent carcinogen
NNK (4-(methylnitrosamino)-1-(3-pyridyl)-1-butanone),
was not different from that of controls. However, the re-
searcher who presented these negative results to the public
surprisingly stated that they were “disappointing from a sci-
entific point of view” (sic) and, for this reason, refrained
from detailing all of them [41, 42].
If (absurd hypothesis) the toxicity tests run by the US-
AUB thanks to the smoking robot had some reality, then
epidemiologic studies should provide high figures for risks
of cancer, to start with. On the contrary, the first cancer aeti-
ological studies on hookah smoking and cancer (which also
compared risk with cigarettes) show that, despite the con-
sumption of huge amounts of coarse tobacco of poor quality
over decades, exclusive users of hookah had biological
markers of cancer (CEA) much less elevated than cigarette
consumers [11]. According to Indian researchers, local hoo-
kahs can be filled up to 375g tobacco a day [43]. By the time
the study was led, the authors did not even discuss the ques-
tion of whether or not, the users (the heavy ones in particu-
lar) did change the water or not. It appeared later that, in the
same region (Kashmir/Punjab), water is barely changed, not
to mention its possible contamination [44]. In the light of
this new information, the results of such pioneering studies
speak by themselves until similar detailed solid investiga-
tions are led [11]. Amazingly, after seven years from this
pioneering work, no other similar study has been published
on this issue.
4. SHISHA, E-CIGARETTES AND PASSIVE SMOK-
ING
Electronic cigarettes were first viewed as efficient harm
reduction tools although later described in many antismoking
publications as entailing an “unknown” “toxicity”… Interest-
ingly, in the light of the already mentioned global confusion,
few scientists working on this new product have noted that
the designers of the E-cigarette actually drew their inspira-
tion from the very principle of WFTSPs [20]. Furthermore, if
shisha smoking had to be compared with other tobacco use
methods, E-cigarettes, not regular ones, should have been the
“natural” candidates from the beginning. Indeed, when cor-
rectly prepared and set up (use vs. misuse), a modern shisha
does generate an aerosol more chemically similar to the
(nicotine and flavours) vapour generated by an E-cigarette.
Unfortunately, a great part of the global mix-up (among re-
searchers as well as many users) is due to the fact that, un-
like sealed cigarettes, it is always easy to tinkle (and users,
particularly the inexperienced ones, do) with the charcoal (its
nature, pressure, position above the bowl, etc.) and its con-
tact (particularly the duration of this contact) with the smok-
ing mixture. In each given situation, this invariably results in
totally different chemical profiles for the generated aerosol.
In such a biased configuration, the flavoured smoking mix-
ture (moassel: to mention the one exclusively targeted by
««waterpipe»» antismokers) packed inside the bowl (below
the aluminium thermal screen) will not – particularly in the
vicinity of the geometric spot beneath the glowing embers-,
be heated but literally charred and burnt with the expected
negative chemical consequences (what actually happens in
the US-AUB smoking robot “protocol”).
Fig. (4). Harm reduction in practice. The Tunisian inverted Keskes
(sieve) is a vaporising ball in use in many cafes of the country. Its
proper use needs some “training” in order to avoid causing the in-
verse effect (burning the moassel instead of just vaporising its ac-
tive principles).
In the absence of any scientific debate, transparency and
help from public health officials, it is interesting to note that
WFTSP users have now successfully designed, by them-
selves, bowls in which the heating source (charcoal embers)
is kept at bay from the flavoured smoking mixture (ta-
bamel/moassel) thus making the inhaled aerosol even more
comparable with the vapour produced by E-cigarettes (See
Fig. 2, 4). Such a harm-reduction concern stems from the
same basis as the one which led to the design of a non-
charcoal powered shisha pipe [6, 45].
Unfortunately, many so-called “tobacco harm reduction”
advocates ignore these facts and, while they were known in
the past for being critical and even radical regarding the bad
science (on regular cigarettes and smokeless tobacco) pub-
lished by antismoking researchers, many of them have sur-
prisingly endorsed the latter’s biased discourse on the
WFTSP “global epidemic”. The case of a French team, al-
ready criticised elsewhere [20], is interesting because it re-
6 The Open Medicinal Chemistry Journal, 2015, Volume 9 Kamal Chaouachi
cently compared the E-cigarette aerosol with that generated
by a regular cigarette and shisha, however deceivingly gloss-
ing over a key chemical difference between both [46]. In-
deed, it is quite deceptive to quantitatively compare cigarette
and WFTPs regarding PM10, PM2.5 or nanoparticles [47].
Certainly, environmental tobacco smoke (ETS) is made up
of millions of particles of different sizes but their composi-
tion (nicotine, hydrocarbons, phenols, heavy metals and
glycerol) is amazingly never advertised. The chemical pro-
file of cigarette ETS is in fact completely different from that
generated by a WFTSP [20]. Consequently, such compari-
sons are unscientific and are obviously made to deceive the
broad public and lawmakers [20]. A few years back, the case
of cigarette third-hand smoke was already scientific non-
sense. Here, one can figure out what such a hyping of risks
amounts to when it comes to WFTSP smoke, known to be
dozens of times less concentrated [35, 48].
5. LACK OF EVIDENCE FOR SHISHA “NICOTINE
“ADDICTION””
The use of quotation marks is very important here be-
cause it is possible that among heavy smokers (several ses-
sions a day) of certain types of pipes (and only certain pipes)
filled with certain varieties of tobacco (not the flavoured
one), some form of dependence may have remained. Of in-
terest are also those who have switched, in a recent or more
remote past, from cigarette smoking to tumbak or jurak use
(See Figs. 1, 3). Unfortunately for such individuals, and for
some unclear reason never described or studied, some fea-
tures of their previous smoking behaviour (cigarette, tumbak,
jurak) may have outlasted. However, when it comes to the
now world popular flavoured smoking mixture (moas-
sel/tabamel) (See Fig. 2), five arguments at least shatter the
new dogma (“addiction”):
a There is no evidence of the existence of such a thing as
shisha “nicotine “addiction”” and the best objection is
that in almost all related surveys [49], the great majority
(80% and more) of users consistently state that they can
“quit” at any moment, spontaneously pointing out that
they can remain several days without feeling such things
as “craving” for their “drug”. Here, the corresponding
percentages for cigarette users should be borne in mind.
They are actually the exact opposite: only some 10% are
recreational while the remaining ones are addicted. Fur-
thermore, in some of these surveys, the directed ques-
tions are asked in such a biased way (for instance: “Do
you know that hookah is associated with cancer, etc. […]
and that experts have demonstrated that it is addictive
too”, preferably repeated several times before and during
the course of the interview…) that the respondents have
generally no other choice than to “admit” that they it is
“true” and that they did not “realise” at first that they
were actually “hooked”...
b Any observer should not downplay the effect of wide-
spread continuous scaring propaganda in the mainstream
media (in the age of globalisation and information tech-
nologies…). This is obviously part of the antismoking ac-
tivists' strategy. However, scientific integrity commands
that independent researchers avoid such unethical meth-
ods. For instance, the credibility of WHO ««waterpipe»»
experts, supervised by the TobReg group, having already
published a flawed report on this issue [24], is once again
stained when, in the wake of a first world ««waterpipe»»
antismoking conference (Oct. 2013), a main leading
««waterpipe»» antismoking expert, and main co-author
of the WHO report, dares state in the popular press that
shisha is more addictive than a hard drug like cocaine
[24, 50].
c The “nicotine “addiction”” dogma has been directly and
uncritically “translated”/imported from the field of ciga-
rette studies in spite of its flawed premises as knowl-
edgeable scholars highly concerned with scientific integ-
rity have been repeating for almost three decades now
[51].
d Since one cigarette puff is supposed to be enough to trig-
ger life addiction [52], ««waterpipe»» antismoking re-
searchers have uncritically carried on several experi-
ments and “meta-analyses” in an endeavour to (try to) es-
tablish that shisha produces “substantial” levels of nico-
tine (even if the corresponding figures are consistently
much lower than in cigarettes). While they admit that the
use of hookah is often recreational, they stress that young
people could nonetheless get addicted and that it would
actually represent a “gatewayto cigarette use. There is
absolutely no evidence for such gratuitous speculations
and exaggerations. Yet, existing data from the field and
produced by antismoking researchers themselves, show
the opposite [53]. ««Waterpipe»» antismoking research-
ers, who wish to demonstrate the relevance of the “gate-
way” theory [53], should not, as they are doing with E-
cigarettes, confuse correlation and causation and are in-
vited to carry out longitudinal surveillance [54]. Yet, re-
cent search in the USA relevantly found that: “hookah
was the most tried product (38%), but cigarettes were
most often the first product ever tried (51%). First prod-
uct tried did not predict current tobacco use and non-use,
but individuals who first tried SLT [smokeless tobacco]
or cigarettes (rather than hookah or ETPs [Emerging
Tobacco Products]) were more likely to be poly tobacco
users […] However, uptake of ETPs is poor, unlike ciga-
rettes and SLT, and does not appear to lead to significant
daily/non-daily use of cigarettes and SLT.” [55].
e Studies on nicotine and its metabolites have been, in most
(if not all) cases, carried out on volunteers without distin-
guishing between smokers of non addictive smoking mix-
tures (such as, e.g., flavoured moassel/tabamel) and those
of other products (such as tumbak and jurak for example)
(See Figs. 1, 2, 3) and even without taking into account the
fact, of utmost importance, that some of the volunteers
were ex-cigarette smokers having switched to shisha
smoking [56]. Therefore, most (if not all) studies (and the
corresponding “meta-analyses” and “systematic reviews”)
so far are stained with a serious methodological flaw
[37, 57]. Referring to a so-called ««waterpipe»» depend-
ence scale” is highly misleading and adding fuel to the
global confusion. Independent researchers should medi-
tate on how Karl Fagerström himself, the very scientist
whose name was given to the famous test (Fagerström
Test for Nicotine Dependence) and on which the above
mentioned scale is based, finally admitted that “nicotine
“addiction”” is not equivalent to tobacco dependence
[58].
Use & Misuse of Water-filtered Tobacco Smoking Pipes The Open Medicinal Chemistry Journal, 2015, Volume 9 7
Fig. (5). Different devices produce, in each case, a qualitatively different chemical smoke and induce different health effects, particularly in
case of misuse as this happens with inexperienced users. Even if some health effects may be similar to those affecting cigarette smokers, this
is generally due to a specific chemical or group of chemicals. This does not mean that all water filtered tobacco smoking pipes do cause the
“same effects” as cigarettes.
In sum, ««waterpipe»» nicotine “addiction” sounds as
one of the greatest fallacies in tobacco research… On one
hand, the research community and the broad public alike
have to admit that we would be in presence of a 400 year-old
“global “epidemic”. On the other, the authors of the WHO
flawed report on ««waterpipe»» still are at variance about
whether its users are dependent or not… For some, WFTSP
would be “addictive” because “some [sic, actually less than
5% in the world…] smokers experience withdrawal” [59].
For others, there would be “many users” (sic) who “exhibit
signs of dependence”) [60].
6. THE EPIDEMIOLOGIC CONCEPT OF PREVA-
LENCE HAS BEEN REVISITED
Just as the definition of an “epidemic” has been misrep-
resented, there is now a prevalent abuse of another key no-
tion: that of prevalence. Unlike cigarettes, oriental pipes are
rather used in a sporadic way. Even under its popularised
modern flavoured-moassel/tabamel based form outside Asia
and Africa (See Fig. 2), it is used one to three times a week
on average. Consequently, it is clear that its users cannot be
“exposed to smoke over a longer period of time than a typi-
cal cigarette” [61], not to mention the different smoke chem-
istry as stressed before and backed with several examples.
More and more frequently, and as a result of over-citing bi-
ased or false results [62] particularly a ten-year old “review
full of scientific errors, which paved the way to the WHO
flawed report [24, 63, 64], prevalence figures are sometimes
compared in a deceiving way. For instance, one of the chief
authors of the above mentioned report stated somewhere that
in Jordan the prevalence “was more than double that of ciga-
rette”. Now, far from such a country, most researchers will
not necessarily understand that shisha is not smoked as fre-
quently as a cigarettes but, on average, dozens of times less.
The dissimulation of such elementary facts keeps in tune
with other in the field of toxicity. For instance, the total phe-
nolic compounds found by the German antismoking team
were 205g (vs. 73g for a single cigarette) [8]. Admitting
the figures actually reflected unbiased measures, this would
mean that a single WFTSP session is “equivalent” (consider-
ing the toxicity of phenols only) to only 3 cigarettes. If we
now take into consideration the actual smoking frequency,
considering a usual smoker of 20 cigarettes a day (and that
of a shisha smoker of between 0.14 pipe per day and 0.43
pipe a day), the purported toxicity of WFTSP appears to be
of a completely different order of magnitude… In this con-
text, it is amazing to read from the German antismoking
team itself that phenolic compounds (as measured by them-
selves [8]) are cause for concern” even more that some of
them are completely dissolved in the water tank.
7. ETHICAL ISSUES
7.1. The Coffee, Tea and Barbecue “Global Epidemics
In the light of the above discussed issues, the first ethical
concern may take the form of a simple question. May one
picture what would be the reaction of the scientific commu-
nity if, tomorrow, scientists succeeded in publishing in the
biomedical peer-reviewed literature claims that coffee and
tea, or even the barbecue, have actually become “global
8 The Open Medicinal Chemistry Journal, 2015, Volume 9 Kamal Chaouachi
Fig. (6). Activity concentration of 210Po and tobacco content in cigarette, moassel and jurak (a), 210Po activity percentage released in smoke
and remained in ash and filter (b), daily and annual intake of Po-210 activity, Bq, due to cigarette, moassel and jurak smoking (c) and annual
committed effective dose due to 210Po and 210Pb intake via smoking (source: Khater AE, Abd El-Aziz NS, Al-Sewaidan HA, Chaouachi K.
Radiological hazards of Narghile (hookah, shisha, goza) smoking: activity concentrations and dose assessment. J Environ Radioact. 2008
Dec; 99(12): 1808-14).
epidemics”? The question is even more relevant that coffee
and tea are known to have spread across the world by the
same time in history as WFTSP (16
th
-17
th
centuries) [1], and
that the barbecue itself produces smoke and is known for
generating great quantities of toxic chemicals like PAHs, CO
and benzene [3, 4]. In view of the absence of reaction on
behalf of researchers, ethics committees outside or inside
scientific editorial groups, one can easily conclude that, as
far as oriental pipes are concerned, the issue seems affected
by double standards.
7.2. Measuring Poor Hygiene Instead of Actual Health
Effects
It appears that biomedical research ethics is seriously
breached when, and just to take one example, toxicity studies
hype the risk of cancer (including in the mainstream media)
supposedly associated with WFTSP use. The problem is that
the corresponding statements are “supported” by experi-
ments in which the water of the ««waterpipe»» was not
changed between sessions [5, 27]. Even the question of the
violated protection of human subjects was once raised in
relation to an amazing experiment in which, not only water
had not been changed but also, ventilation not secured [28,
29]. The bottom line is that, most of the time, what such
studies actually measure is certainly not the toxicity of hoo-
kah smoking “per se” but the risk of poor hygiene, or mis-
use, including “modelled” misuse as the US-AUB smoking
robot based experiments show [1, 5].
7.3. Bibliometric Performance
Then there is the question of over-citing biased erroneous
publications in the available abundant ««waterpipe»» litera-
ture. For instance, when the authors of a Jordanian study
(coming up with negative results) cite, in a European public
health journal, the publications of the US-SCTS up to 80
times in a manuscript of only 6 pages, and that 64 of such
citations concern one chief author, namely the head of that
organisation, and that it appears up 22 times in the first two
paragraphs, this actually raises ethical concerns [14, 64]. The
point here is that such breaches are not isolated cases but
have been representing the actual trend for one decade now.
This topic takes a renewed importance because some parties
are now trying to draw a “bibliometric” picture of research in
this field [65]. Yet, what is actually measured in such a pro-
ject is an artefact due to a methodological vicious circle.
Such an unnoticed artefact allows an unscientific article to be
cited up to 200 times, not to mention the monopoly of re-
search as the imposed model of the US-AUB smoking robot
shows [1].
7.4. Three Other Phenomena
Three phenomena are a direct result of over-citing
“cherry-picked” research in this field. The first one is the
open dismissal, on no scientific ground, of peer-reviewed
scientific publications (bibliographical bias). Most of the
time, the obvious reason is that the corresponding literature
presents negative results even if the related studies represent
substantial documents such as, medicine theses, particularly
those focussing on lung function, not to mention an early
comprehensive transdisciplinary doctoral thesis [1, 66, 67].
Such a bias is what a world renowned epidemiologist, who
issued a famous “plea for epistemological modesty”, de-
scribed as the “tendency of authors and journal reviewers
and editors to report and publish “positive” or “statistically
significant” results over “null” or “non –statistically sig-
Use & Misuse of Water-filtered Tobacco Smoking Pipes The Open Medicinal Chemistry Journal, 2015, Volume 9 9
nificant” results, particularly if the findings appear to con-
firm a previously reported association (i.e., the “bandwagon
effect”). As with other forms of bias, preferential publica-
tion generates a false sense of consistency among studies”
[68]. However, one example of such “false-positive” results
was recently highlighted in the biomedical press and in-
volved the author of the above critical statement himself [5].
Unsurprisingly, the research community should be aware
that such ethical breaches have also led to a second problem
represented by actual cases of plagiarism in ««waterpipe»»
research, be the latter based on direct copying or paraphras-
ing as the Elsevier Group notes [69]. Ideally, and in agree-
ment with recommendations of ethics committees, cases of
plagiarism are generally solved in a “diplomatic” way: e.g.,
through a Letter to the Editor forcing the faulty authors to
openly cite the work they first decided to ignore. This has
been done in relation to the core reference cited in the pre-
sent article [1, 70, 71]. Then, we have a third ethical conse-
quence, unprecedented in the biomedical field. It relates to
the history of science since it was arbitrarily announced that
research on WFTSPs has actually begun by year 2002 [37].
Interestingly, the last date matches the beginning of activity
at the US-AUB and US-SCTS. Of course, this is untrue since
research in this field has been documented back to 1622
[72]. The obvious objective of such a rewriting of research
history in this field was to make tabula rasa of a long tradi-
tion of independent (from both the tobacco and pharmaceuti-
cal industries) valuable medical research of the past decades.
During such a golden period, pioneers of tobacco science
such as Dietrich Hoffmann, Ernst Wynder, Angel Roffo and
many other physicians and cancer specialists, particularly in
Asia and Africa, did study –objectively and independently–
hookah, narghile and shisha smoking. The dismissal of such
figures was striking in the WHO flawed report [11, 24]. In a
normal situation and even assuming (absurd hypothesis) that
the world were facing a “global “epidemic””, the first logical
step should have been to clarify to what extent the “new”
findings, i.e. since 2002, are in agreement, or not, with those
published by the above mentioned great names of tobacco
research in this field. Amazingly, this has never been done.
The clear reason, which has nothing to do with science, is
that, most of the time, the pioneers of investigation in this
field came up with negative results in their studies (from
smoke toxicity to cancer and lung function). The most recent
evidence for this regrettable trend is that even when ««wa-
terpip» antismoking teams themselves get negative results,
they are not cited in the available literature [19].
7.5. Epistemological Contradiction of ««Waterpipe»»
Research
Any independent observer is entitled to ask why ««wa-
terpipe»» antismoking teams, apparently so concerned with
the health of populations, have been publishing alarming
papers on only one type of WFTSP and definitely ignored all
the others particularly adapted for tumbak, jurak, etc. (See
Figs. 1, 3, 5). Yet, the smokers of the latter are actually much
more numerous than those of the former type. The contradic-
tion is striking since a neologism as ««waterpipe», which has
led astray so many physicians and epidemiologists in the
world, is supposed to cover all WFTSPs of the world: from
hookah to narghile, shisha, etc., and all of the corresponding
products consumed in them. What is even more concerning
is that not only the latter’s use (i.e. traditional several-
centuries old) is much more important (prevalent) but they
are most of the time served in a mixed way in the very places
where studies have been carried out (e.g., coffee houses…).
A rare independent study from Kuwait exemplifies this point
[15]. It is once again amazing that the latter fact (qualifying
for another serious methodological flaw) is silenced in most
of the corresponding publications. Indeed, the chemistry of
smoke and the potential health effects are completely differ-
ent in both cases (e.g., between flavoured and unflavoured
shisha smoking, not only because the products are different
but also because of the set up involving or not a direct con-
tact between the heating or burning source and the smoking
product (See Figs. 1, 2, 3).
Finally, in a fair number of cases, researchers draw to-
tally irrelevant parallels with other studies (which are about a
completely different product) as this happened recently in
such a country as Iran [39, 40]. One solution to such a great
multi-dimension methodological flaw would be that, in each
given situation, the researchers specify what kind of water
pipe (in two words) is referred to. It just varies, from one
setting to other and from one country to other and from one
group of users to other. As a consequence, it is clear that it is
not a mere matter of “vocabulary” preference which would
be easily fixed by adding one to three words “(narghile, hoo-
kah, shisha)” in the title of an article in order to make it sud-
denly and scientifically sound. The clarification must be
made from the outset, in the abstract itself and in the intro-
duction, methods, discussion, results sections and conclusion
of each publication. For instance, the authors should state
something like: “In this report, we have studied smokers of
this type of pipe and product (e.g., moassel/tabamel) (See
Fig. 2). We have or not distinguished them from the users of
this or that other product (e.g. tumbak, jurak) (See Figs. 1,
3). Moreover, a proportion of x% of our smokers were pre-
vious cigarette users and y% were actually smokers who had
switchedin a more or less recent past- from cigarette to this
or that type of tobacco or tobacco-based product. There are
also other details of utmost importance such as the use -or
not- of a thermal screen and of what type (aluminium, zinc
plate, vaporising bowl, etc.) and, of course, the classical and
not less key questions about hygiene: e.g., “how often do
you change the water” [5]. Any infringement to such basic
methodological rules amounts to a form of reductionism (of
a complex issue) and, therefore, needs to be exposed.
CONCLUSION
Thanks to striking examples of serious contradictions ex-
posed here and in a previous article [5], we have shown that
most toxicity studies have actually demonstrated “how NOT
to use” WFTSPs... Scientific ethics commands that public
health organisations should stop delaying the dissemination
of practical minimal recommendations to millions of
WFTSP users across the world. Just calling for “eradication”
(sic) or immediate “implementation” of a prohibitionist
agenda of the FCTC type [9, 10, 22, 25, 35], is reminiscent
of those self-righteous activists who, one century ago in the
USA, pushed for alcohol prohibition. In the end, it proved to
be a total human, economic and socio-cultural failure. Re-
search on WFTSPs should recover the independence that it
10 The Open Medicinal Chemistry Journal, 2015, Volume 9 Kamal Chaouachi
has unfortunately lost one decade ago and remain open to all
views, particularly those independent from the African and
Asian continents, and not only to a heavily funded elite who
has not brought so far the least evidence of its alleged excel-
lence. Yet, the opposite is true. The first step should be to
address the numerous ethical breaches reviewed before. The
publication of negative results should be encouraged along-
side positive findings so that the practice of public health be
enhanced for the benefit of populations before that of re-
searchers [1]. For example, a recent spontaneous Letter to
the Editor by researchers in Thailand is a model to follow
[73]. By their independent discussion about the importance
of dose-response aspects and genetic factors, the authors are
reminiscent of others who openly, and as early as 1955, dis-
cussed in the Lancet, the possibility of a null, low or reduced
risk of cancer among narghile smokers [12]; a hypothesis
positively tested seven years and half a century later, respec-
tively [11, 13]. A key message to be disseminated to both
users and non-users of WFTSPs is that the great majority of
the toxicity (90% and much more) comes from the charcoal
in a way very similar to the use and misuse of barbecues. On
one hand, important amounts of tobacco may be consumed
in WFTSPs (“up to 375g tobacco”) [43]. On the other, the
quality of this (coarse) tobacco is generally low, particularly
in Asia and Africa. A reasonable anthropological conclusion
can now be drawn from these two facts and the toxicological
and medical considerations reviewed in this article [5, 11].
WFTSPs (from hookahs to narghiles and from shishas to
mada'i) would represent the oldest tobacco harm reduction
technique in the world. It has been a natural one, long before
the arrival of the E-cigarette which, even it may be more
efficient, is based on the principle of the former: vapourising
nicotine and flavours [5, 11, 20].
ABBREVIATIONS
WFTSPs = Water Filtered Tobacco Smoking Pipes
US-AUB = US American University of Beirut
US-SCTS = US-Syrian Centre for Tobacco Studies in
Aleppo
CONFLICT OF INTEREST
The author declares that he has no competing interests.
He has never received financial or non-financial, direct or
indirect, funding either from pharmaceutical companies
(nicotine ‘‘replacement’’ therapies and products) or from the
tobacco industry. He has been, at times between years 2000
and 2007, an active member of the world antismoking Glob-
alink network sponsored by the pharmaceutical industry
(Pfizer in particular). This organisation counts some 6,000
members working with: ministries of health; antismoking
NGOs; the World Health Organisation and its relevant bod-
ies (TobReg, the Study Group for the Regulation of Tobacco
Products; the “Tobacco Free Initiative”; the regional bu-
reaux; etc.); the Cochrane Review Tobacco Addiction
Group; etc. Globalink also maintains strong links with the
main antismoking journals: “Tobacco Control” most impor-
tantly; “Nicotine and Tobacco Research; “Addiction; some
US biomedical journals which regularly publish articles on
tobacco issues, etc. Since some views expressed in the pre-
sent article could perhaps be seen as influenced by such an
experience, the author wishes to confirm that both the scien-
tific presentation of facts and the necessary discussion exclu-
sively rely on the available world peer-reviewed scientific
literature.” Dr. Kamal Chaouachi is also co-founder of the
French non-profit association for independent multidiscipli-
nary research (medicine, toxicology, history, psychology,
sociology, anthropology, economics, etc.) on oriental pipes.
ACKNOWLEDGEMENTS
Declared none.
PATIENT’S CONSENT
Declared none.
REFERENCES
[1] Chaouachi, K. Tout savoir sur le narguilé. Société, culture, histoire
et santé [Eng.: Everything about hookahs. society, culture, origins
and health aspects], 2
nd
ed.; L’Harmattan: Paris, 2012. Previously
published by Maisonneuve & Larose, Paris, 2007, ISBN: 978-2-
7068-1954-4. Preface by Pr Robert Molimard. Extract from the
first transdisciplinary doctoral thesis on this issue.
[2] Yüksel, Hülya. Tütün kontrolünde neolberal poltkalarin yansi-
masi ve salik etm [The influence of neoliberal policies on
“tobacco “control”” and health education]. Dumlupnar Üni. So-
syoloji Bölümü. 2014, 11 pages, [Accessed 8 Dec. 2014].
https://www.academia.edu/4007251/The_Influence_of_Neoliberal_
Policies_on_Tobacco_Control_and_Health_Education
[3] Olsson, M.; Petersson, G. Benzene emitted from glowing charcoal.
Sci. Total Environ., 2003, 303, 215-220.
[4] Rahman, M. M.; Kim, K. H. Release of offensive odorants from the
combustion of barbecue charcoals. J. Hazard Mater. 2012, 215-6,
233-242.
[5] Chaouachi, K. False positive result in study on hookah smoking
and cancer in Kashmir: measuring risk of poor hygiene is not the
same as measuring risk of inhaling water filtered tobacco smoke all
over the world. Br. J. Cancer., 2013, 108, 1389-1390.
[6] Chaouachi K. Public health intervention for narghile (hookah,
shisha) use requires a radical critique of the related ‘‘standardised’’
smoking machine. J. Public Health, 2009, 18, 69-73.
[7] Chaouachi, K. Assessment of narghile (shisha, hookah) smokers’
actual exposure to toxic chemicals requires further sound studies.
Libyan J.of Med., 2011, 6, 5934-5939.
[8] Schubert, J.; Müller, F.D.; Schmidt, R.; Luch, A.; Schulz, T.G.
Waterpipe smoke: source of toxic and carcinogenic VOCs, phenols
and heavy metals? Arch. Toxicol., 2014, Sep 24. [Epub ahead of
print]
[9] Nakkash, R.; Afifi, R.; Maziak, W. Research and activism for to-
bacco control in the Arab world. Lancet, 2014, 383, 392-393.
[10] Maziak, W.; Nakkash, R.; Bahelah, R.; Husseini, A.; Fanous, N.;
Eissenberg, T. Tobacco in the Arab world: old and new epidemics
amidst policy paralysis. Health Policy Plan.,
2013,
Doi:10.1093/heapol/czt055
[11] Sajid, K.M.; Chaouachi, K.; Mahmood, R. Hookah smoking
and cancer. Carcinoembryonic antigen (CEA) levels in exclu-
sive/ever hookah smokers. Harm. Reduct. J., 2008, 5-19.
http://www.pubmedcentral.nih.gov/articlerender.fcgi?tool=pubmed
&pubmedid=19440416
[12] [Anon.] Annotations, The Lancet, 1955, 392-3.
[13] Rakower, J.; Fatal, B. Study of Narghile Smoking in Relation to
Cancer of the Lung. Br. J. Cancer, 1962, 16, 1-6.
[14] Al-Safi, S.A.; Ayoub, N.M.; Albalas, M.A.; Al-Doghim, I.; Aboul-
Enein, F.,H. Does shisha smoking affect blood pressure and heart
rate ? J. Public Health, 2009, 17, 121-126.
[15] Al Mutairi, S.S.; Mojiminiyi, O.A.; Shihab-Eldeen, A.A.; Al
Sharafi, A.; Abdella, N. Effect of smoking habit on circulating adi-
pokines in diabetic and non-diabetic subjects. Ann. Nutr. Metab.,
2008, 52, 329-334.
[16] Khater, E.M.; Amr, M.; Chaouachi, K. Elemental characterization
of shisha moassel smoking mixtures using ICP-MS and comparison
with other tobacco products. Wulfenia J., 2014, 21, 428-449.
Use & Misuse of Water-filtered Tobacco Smoking Pipes The Open Medicinal Chemistry Journal, 2015, Volume 9 11
[17] Ben Saad, H.B.; Khemiss, M.; Nhari, S.; Essghaier, M.B.; Rouatbi,
S. Pulmonary functions of narghile smokers compared to cigarette
smokers: a case-control study. Libyan J. Med., 2013, 8, 1-8.
[18] Mohammad, Y.; Shaaban, R.; Abou Al-Zahab, B.; Khaltaev, N.;
Bousquet, J.; Dubaybo, B. Impact of active and passive smoking as
risk factors for asthma and COPD in women presenting to primary
care in Syria: first report by the WHO-GARD survey group. Int. J.
Chron. Obstruct. Pulmon.. Dis., 2013, 8, 473-482.
[19] Apsley, A.; Galea, K.S.; Sánchez-Jiménez, A.; Semple, S.; Ware-
ing, H.; Van Tongeren, M. Assessment of polycyclic aromatic hy-
drocarbons, carbon monoxide, nicotine, metal contents and particle
size distribution of mainstream Shisha smoke. J. Environ. Health
Res., 2011, 11, 93-103.
[20] Chaouachi, K. Hookah (shisha, narghile) smoking and environ-
mental tobacco smoke (ETS). A critical review of the relevant lit-
erature and the public health consequences. Int. J. Environ. Res. Pub-
lic Health, 2009, 6, 798-843. http://www.pubmedcentral.nih.gov/ ar-
ticlerender.fcgi?tool=pubmed&pubmedid=19440416
[21] Chaouachi, K. Is medical concern about hookah environmental
tobacco smoke hazards warranted ? [A Tribute to Gian Turci, who
has recently passed away]. The Open Gen. Internal Med. J., 2009,
3, 31-3.
[22] Bahelah, R. Waterpipe tobacco labeling and packaging and World
Health Organization Framework Convention on Tobacco Control
(WHO FCTC): a call for action. Addiction, 2013, S0091-3057.
[23] ASH (Action on Smoking and Health). ““Shisha 200 times worse
than a cigarette” say Middle East experts””. 2007 (prepared by
Martin Dockrell)[accessed 13 June, 2008]. Based on an interview
with Wasim Maziak and Alan Shihadeh. Sub-heading: “Three lead-
ing experts from across the Middle East have warned that exclud-
ing “shisha bars” when England goes smokefree on July 1 could
worsen the grave inequalities in health that already affect ethnic mi-
norities”. [Accessed 8 Dec. 2014]. http://www.ash.org.uk/ media-
room/press-releases/shisha-200-times-worse-than-a-cigarette- say-
middle-east-experts
[24] Chaouachi, K. A Critique of the WHO's TobReg “Advisory Note”
entitled: “Waterpipe Tobacco Smoking: Health Effects, Research
Needs and Recommended Actions by Regulators. J. Negat. Results
Biomed., 2006, 5, 1-17. http://www.ncbi.nlm.nih.gov/pmc/ arti-
cles/PMC1664583/
[25] Jawad, M.; Bakir, A.M.; Ali, M.; Jawad, J.; Akl, E.A. Key health
themes and reporting of numerical cigarette–waterpipe equivalence
in online news articles reporting on waterpipe tobacco smoking: a
content analysis. Tob. Control, 2015, 24
, 43-47.
[26] Djordjevic, M.V.; Doran, K.A. Nicotine content and delivery
across tobacco products. Handb. Exp. Pharmacol., 2009, 192, 61-
82.
[27] Jacob, P.; Abu Raddaha, A. H.; Dempsey, D.; Havel, C.; Peng, M.;
Yu, L.; Benowitz, N.L. Comparison of nicotine and carcinogen ex-
posure with water pipe and cigarette smoking. Cancer Epidemiol.
Biomarkers Prev., 2013, 22, 765-772.
[28] Chaouachi, K. Hookah (shisha, narghile, “water pipe”) indoor air
contamination in German unrealistic experiment. Serious methodo-
logical biases and ethical concern. Food Chem. Toxicol., 2010, 48,
992-995.
[29] Fromme, H.; Dietrich, S.; Heitmann, D.; Dressel, H.; Diemer, J.;
Schulz, T.; Jörres, R.A.; Berlin, K.; Völkel, W. Indoor air contami-
nation during a waterpipe (narghile) smoking session. Food Chem
Toxicol., 2009, 47, 1636-1641.
[30] Nassar, A.H.; Abu-Musa, A.; Hannoun; A.; Usta, I.M. Authors
reponse: nargile smoking and its effect on in vitro fertilization: a
critical eye on the available literature. Eur. J. Obstet. Gynecol.,
2010, 152, 116.
[31] Underwood M. Shisha: The Middle East’s favourite toxin. The
National (Emirates), 2013. [Accessed 8 Dec. 2014].
http://www.thenational.ae/uae/health/shisha-the-middle-easts-
favourite-toxin#full
[32] CDC. Evidence: New CDC study finds dramatic increase in e-
cigarette-related calls to poison centers. [Accessed 8 Dec. 2014].
http://www.cdc.gov/media/releases/2014/p0403-e-cigarette-
poison.html
[33] Goldman, A.L. Carboxyhemoglobin levels in primary and secon-
dary cigar and pipe smokers. Chest, 1977, 72, 33-35.
[34] Rylander, R. Environmental Tobacco Smoke Effects on the Non-
smoker. Workshop; Bermuda, March 27-29, University of Geneva:
Geneva, Switzerland, 1974.
[35] Kassem, N.O.; Daffa, R.M.;Liles, S.; Jackson, S.R.; Kassem, N.O.;
Younis, M.A.; Mehta, S.; Chen, M.; Jacob, P.3rd; Carmella, S.G.;
Chatfield, D.A.; Benowitz, N.L.; Matt, G.E.; Hecht, S.S.; Hovell,
M.F. Children’s Exposure to Secondhand and Thirdhand Smoke
Carcinogens and Toxicants in Homes of Hookah Smokers. Nicotine
Tob. Res., 03 March 2014. Doi: 10.1093/ntr/ntu016.
[36] Saadawi, R.; Figueroa, J.A.L.; Hanley, T.; Caruso, J. The hookah
series part 1: total metal analysis in hookah tobacco (narghile,
shisha)—an initial study. Ana.l Methods, 2012, 4, 3604-3611
[37] Chaouachi, K.; Sajid, K.M. A critique of recent hypotheses on oral
(and lung) cancer induced by water pipe (hookah, shisha, narghile)
tobacco smoking. Med. Hypotheses, 2010, 74, 843-846.
[38] Layoun, N.; Saleh, N.; Barbour, B.; Awada, S.; Rachidi, S.; Al-
Hajje, A.; Bawab, W.; Waked, M.; Salameh, P. Waterpipe effects
on pulmonary function and cardiovascular indices: a comparison to
cigarette smoking in real life situation. Inhal. Toxicol., 2014, 26,
620-627.
[39] Boskabady, M.H.; Farhang, L.; Mahmodinia, M.; Boskabady, M.;
Heydari, G.R. Comparison of pulmonary function and respiratory
symptoms in water pipe and cigarette smokers. Respirology, 2012,
17, 950-956.
[40] Chaouachi, K. Lung function of water pipe (Qalyan, Narghile,
Shisha, Hookah) users vs. cigarette smokers in Iran [Critical analy-
sis of the study]. Tabaccologia, 2013, 3, 18-29.
[41] Schulz, T.; Dettbarn, G.; Völkel, W.; Hahn, J. Water pipe smoking:
biomarkers of exposure. Audiovisual presentation at 14
th
World
Congress on Tobacco or Health (WCTOH), Bombay, 2009, March
9. Accessed Jan. 2010. http://www.14wctoh.org/abstract/
abs_detail.asp?AbstractID=434
[42] Chaouachi, K.; Sajid, K.M. Cancer risks of hookah (shisha, nar-
ghile) tobacco use require further independent sound studies. Int. J.
Cancer, 2010, 27, 1737-1739.
[43] Muzaffar, M., Dar, N.A. Esophageal cancer in Kashmir (India): An
enigma for researchers. Int. J. Health Sci. (Qassim), 2009, 3, 71-85.
[44] Khlifi, R. Response to comment of Dr. Kamal Chaouachi on
“Shisha Smoking, Nickel and Chromium Levels in Tunisia”. Envi-
ron. Sci. Pollut. Res. Int., 2013, 20, 82-97.
[45] Billard, G.; Chaouachi, K.; De La Giraudiere, A.-P. Hookah with
simplified lighting. US Patent Application, 2005, 2005/0279371
A1. Application number 11/148, 194.
[46] Bertholon, J.F.; Becquemin, M.H.; Roy, M.; Roy, F.; Ledur, D.;
Annesi Maesano, I.; Dautzenberg, B. Comparaison de l’aérosol de
la cigarette électronique à celui des cigarettes ordinaires et de la
chicha [Comparison of the aerosol produced by electronic ciga-
rettes with conventional cigarettes and the shisha]. Rev. Mal.
Respir., 2013, 30, 752-757.
[47] Torrey, C.M.; Moon, K.A.; Williams, D.A.; Green, T.; Cohen, J.E.;
Navas-Acien, A.; Breysse, P.N. Waterpipe cafes in Baltimore,
Maryland: Carbon monoxide, particulate matter, and nicotine expo-
sure. J. Expo. Sci. Environ. Epidemiol. 2014, Apr 16. doi:
10.1038/jes.2014.19. [Epub ahead of print]
[48] Kabat, G. Is “Thirdhand Tobacco Smoke” a valid scientific concept
or a public relations gimmick? The Columbia University Press
Blog, 2009. [Accessed 08 Dec. 2014] http://www.cupblog.org/?
p=493
(accessed 8 Dec. 2014).
[49] Salameh, P.; Aoun, Z.; Waked, M. Saliva cotinine and exhaled
carbon monoxide in real life narghile (waterpipe) smokers: a post
hoc analysis. Tob. Use Insights, 2009, 2, 1-10.
[50] Al-Taher, N. Shisha smoking is more addictive than cocaine, expert
says. Expert says those who smoke hookah likely to switch to ciga-
rettes within three years. Gulf News, 26 Oct. 2013. [Accessed 08
Dec. 2014]. http://m.gulfnews.com/news/uae/general/shisha-smoking-
is-more-addictive-than-cocaine-expert-says-1.1247504
[51] Molimard, R. The myth of nicotine addiction. Tabaccologia, 2013,
3, 18-29.
[52] Dar, R.; Frenk, H. Can one puff really make an adolescent addicted
to nicotine? A critical review of the literature. Harm Reduct. J.,
2010, 7, 10-31.
[53] Carroll, T.; Poder, N.; Perusco, A. Is concern about waterpipe
tobacco smoking warranted? Aust. N. Z. J. Public Health., 2008,
32, 181-182.
[54] Abrams, D.B. Potential and Pitfalls of e-Cigarettes—Reply. JAMA,
2014, 311, 1922-1923.
[55] Meier, E.M.; Tackett, A.P.; Miller, M. B.; Grant, D.M.; Wagener,
T. L. Which nicotine products are gateways to regular use?: First-
12 The Open Medicinal Chemistry Journal, 2015, Volume 9 Kamal Chaouachi
Tried tobacco and current use in college students. Am. J. Prev.
Med., 2015, 48, 86-93.
[56] Macaron, C.; Macaron, Z.; Maalouf, MT.; Macaron, N.; Moore, A.
Urinary cotinine in narguila or chicha tobacco smokers. J. Med. Li-
ban., 1997, 45, 19-20.
[57] Chaouachi, K. More Rigor needed in systematic reviews on “Wa-
terpipe” (hookah, narghile, shisha) smoking. Chest, 2011, 139,
1250-1251.
[58] Molimard, R. Fagerstromo trovas sian vojon al Damasko [“Fager-
ström finds his way to Damascus” (translated by Iro Cyr))]. 26 Nov
2011. [Accessed 08 Dec. 2014]. http://www.formindep.org/ Fager-
stromo-trovas-sian-vojon-al.html
[59] Aboaziza, E.; Eissenberg, T. Waterpipe tobacco smoking: what is
the evidence that it supports nicotine/tobacco dependence? Tob.
Control, 2014. Doi: 10.1136/tobaccocontrol-2014-051910
[60] Asfar, T.; Al Ali, R.; Rastam, S.; Maziak, W.; Ward, K.D. Behav-
ioral cessation treatment of waterpipe smoking: The first pilot ran-
domized controlled trial. Addict. Behav., 2014, 39: 1066-1074.
[61] Dave, B. Why do GDPs fail to recognise oral cancer? The argu-
ment for an oral cancer check list. Br. Dent. J., 2013, 214, 223-225.
[62] West, R.; McIlwaine, A. What do citation counts count for in the
field of addiction? An empirical evaluation of citation counts and
their link with peer ratings of quality. Addiction, 2002, 97, 501-
504.
[63] Maziak, W.; Ward, K. D.; Afifi Soweid, R.A.; Eissenberg, T. To-
bacco smoking using a waterpipe: a re-emerging strain in a global
epidemic. Tob. Control, 2004, 13, 327-333.
[64] Chaouachi, K. Errors and misquotations in the study of shisha,
blood pressure and heart rate in Jordan. J. Pub. Health, 2009, 17,
355-356.
[65] Zyoud, S.H.; Al-Jabi, S.W.; Sweileh, W.M.; Awang, R. A scopus-
based examination of tobacco use publications in Middle Eastern
Arab countries during the period 2003-2012. Harm Red. J., 2014,
11, 1-14.
[66] Khalsi, S. Les manifestations respiratoires liées à la consommation
chronique de narguilé : à propos de 30 cas [Respiratory manifesta-
tions of narghile chronic use]. Thèse de médecine, Tunis, 2005, 56.
[67] Mejri, A. Le Tabagisme par le narguilé [Narghile and tobacco
abuse]. Thèse de médecine, Tunis, Faculté de médecine, 1985, 41.
[68] Boffetta, P.; McLaughlin, J. K.; La, V.C.; Tarone, R.E.; Lipworth,
L.; Blot, W. J. False-positive results in cancer epidemiology: a plea
for epistemological modesty. J. Cancer. Inst., 2008, 100: 988-995.
[69] Elsevier Group Plagiarism. Ethics in Research & Publication.
Accessed 08 Dec. 2014 www.ethics.elsevier.com/pdf/ETH-
ICS_PLA01a.pdf
[70] Chaouachi, K. An open letter against plagiarism and plagiarists.
Tabaccologia, 2009, 1, 46-47.
[71] Zaga V. Plagiarism in biomedical sciences: a bad habit that needs
to be rooted out [Il plagio in campo medico-scientifico: un malcos-
tumbre da estirpare]. Tabaccologia, 2009, 4, 5-7.
[72] Chaouachi, K. Did pre-Columbian mummies smoke tobacco? Evi-
dence in the light of most recent tobaccological & anthropological
findings [Una revisione critica degli elementi di prova ala luce
delle conclusioni tabaccologiche e antropologiche più recenti]. Ta-
baccologia, 2012, 1-2, 31-46.
[73] Wiwanitkit, S.; Wiwanitkit, V. Shisha versus cigarette smoking and
endothelial function. Anadol. Kardiyol. Derg., 2014, May 6. Doi:
10.5152/akd.2014.5410. [Epub ahead of print].
Received: August 18, 2014 Revised: December 27, 2014 Accepted: January 22, 2015
© Kamal Chaouachi; Licensee Bentham Open.
This is an open access article licensed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/-
licenses/by-nc/3.0/) which permits unrestricted, non-commercial use, distribution and reproduction in any medium, provided the work is properly cited.
... Habitually, public opinion, and particularly the medical world, misjudges the harmful effects of narghile use, despite its damaging effects on health (Aslam, Saleem, German, & Qureshi, 2014;Ben Saad, 2010;Bou Fakhreddine, Kanj, & Kanj, 2014;Chaouachi, 2006Chaouachi, , 2009Chaouachi, , 2015El-Zaatari, Chami, & Zaatari, 2015;Waziry, Jawad, Ballout, Al Akel, & Akl, 2017). Up-to-date evidence indicates that narghile use is associated with several adverse health effects including cardiorespiratory, hematological, and reproductive systems (Aslam et al., 2014;Ben Saad, 2010;Bou Fakhreddine et al., 2014;Chaouachi, 2006Chaouachi, , 2009Chaouachi, , 2015El-Zaatari et al., 2015;Waziry et al., 2017). ...
... Habitually, public opinion, and particularly the medical world, misjudges the harmful effects of narghile use, despite its damaging effects on health (Aslam, Saleem, German, & Qureshi, 2014;Ben Saad, 2010;Bou Fakhreddine, Kanj, & Kanj, 2014;Chaouachi, 2006Chaouachi, , 2009Chaouachi, , 2015El-Zaatari, Chami, & Zaatari, 2015;Waziry, Jawad, Ballout, Al Akel, & Akl, 2017). Up-to-date evidence indicates that narghile use is associated with several adverse health effects including cardiorespiratory, hematological, and reproductive systems (Aslam et al., 2014;Ben Saad, 2010;Bou Fakhreddine et al., 2014;Chaouachi, 2006Chaouachi, , 2009Chaouachi, , 2015El-Zaatari et al., 2015;Waziry et al., 2017). An association between narghile use and malignancies, such as lung, oral, and nasopharyngeal cancer, has been suggested (Ben Saad, 2010;Bou Fakhreddine et al., 2014;El-Zaatari et al., 2015;Khemiss, Rouatbi, Berrezouga, & Ben Saad, 2016;Waziry et al., 2017). ...
... The exclusion of alcohol consumers provided the same results (Table 2S in the Appendix) except for the For some years, narghile use has been considered as a global threat and has been given the status of an epidemic by public health officials (Aslam et al., 2014). The harmful effects of narghile use on smokers' biochemical data and metabolic profile highlighted in this study are part of a more general phenomenon (Ben Saad, 2010;Bou Fakhreddine et al., 2014;Chaouachi, 2015;El-Zaatari et al., 2015;Khemiss et al., 2016;Waziry et al., 2017). Although the harmful effects of cigarette consumption on health have been well documented, those of narghile use on biochemical data and/or metabolic profiles are less studied. ...
Article
Full-text available
Studies evaluating the metabolic profiles of ENSs are scarce and presented controversial conclusions. This study aimed to compare the metabolic profiles of ENSs’ and AHNSs’ groups. Males aged 25-45 years and free from a known history of metabolic and/or cardiovascular diseases were included. According to the smoking status, two groups of ENSs and AHNSs were identified. Body mass index (BMI, kg/m2), waist circumference (WC, cm), systolic and diastolic blood pressures (SBP, DBP, mmHg), fasting blood data in mmol/L [blood glycaemia (FBG), triglycerides (TG), total cholesterol (TC), high- and low- density lipoprotein cholesterol (HDL-C, LDL-C)] and obesity status were evaluated. The metabolic syndrome (MetS) was defined according to the 2006-IDF recommendations. Data were expressed as mean±SD or percentages. Compared to the AHNSs’ group (n=29), the ENSs’ one (n=29) had i) higher values of BMI (26.5±2.3 vs. 28.2±3.6), WC (95±7 vs. 100±10) and TG (1.22±0.40 vs. 1.87±0.85); and ii) included a lower percentage of males having low HDL-C (82.7 vs. 62.0%), and higher percentages of males having obesity (6.9 vs. 37.9%) or hypertriglyceridemia (10.7 vs. 51.7%). Both the ENSs’ and AHNSs’ groups: i) had similar values of FBG (5.38±0.58 vs. 5.60±0.37), TC (4.87±1.16 vs. 4.36±0.74), HDL-C (0.92±0.30 vs. 0.82±0.21), LDL-C (3.09±0.98 vs. 2.92±0.77), SBP (117±9 vs. 115±8) and DBP (76±6 vs. 73±7); and ii) included similar percentages of males having normal weight (17.2 vs. 31.0%); overweight (44.8 vs. 62.1%); android obesity (79.3 vs. 59.6%), hypertension (10.3 vs. 10.3%), hyperglycemia (37.9 vs. 48.2%) and MetS (51.7 vs. 34.5%). There is a need to monitor narghile-use among males’ metabolic patients since it alters some components of the MetS.
... Narghile use is frequently associated with several diseases. Hence, numerous studies were published concerning the general effects of narghile use on health (Awan, Siddiqi, Patil, & Hussain, 2017;Ben Saad, 2010;Bou Fakhreddine, Kanj, & Kanj, 2014;Chaouachi, 2015;El-Zaatari, Chami, & Zaatari, 2015;Waziry, Jawad, Ballout, Al Akel, & Akl, 2017;WHO, 2005WHO, , 2015. As inhalation of the toxic substances included in narghile smoke may affect the integrity of the oral cavity (Amer, Waguih, & El-Rouby, 2019) and as dentists may have narghile smokers as their patients, it is essential to inform them of the significantly damaging impacts of its use on some components of the oral cavity, such as the periodontium. ...
... Persson, Bergström, Gustafsson, & Asman, 1999;Ryder, 1994;Ryder et al., 1998). However, since the toxic substances and the chemical profile of narghile smoke are completely different from those of cigarettes (e.g., the mean blood nicotine level in ENSs sitting for a narghile session [~45 min] was lower than that identified in ENSs having smoked 1 cigarette [~5 min] or corresponding to that of 1.7 cigarette when applying a pharmacokinetics model; Ben Saad, 2009;Chaouachi, 2009Chaouachi, , 2015Eissenberg & Shihadeh, 2009;Primack et al., 2016), these two methods of tobacco smoking are hypothesized to induce different health effects in ENSs and ECSs. For instance, one Tunisian study concluded that narghile smoking has less adverse effects on pulmonary function tests than cigarette smoking (Ben Saad, Khemiss, Nhari, Ben Essghaier, & Rouatbi, 2013). ...
Article
Full-text available
Studies evaluating the effects of narghile use on the periodontium present conflicting conclusions. This study aimed to compare the periodontal status of exclusive narghile smokers (ENSs, n = 74) to that of exclusive cigarette smokers (ECSs, n = 74). Males aged 20–40 years were recruited to participate in this comparative study. Information concerning oral health habits (number of yearly visits to the dentist, daily toothbrushing frequency) and tobacco exposure were obtained. Clinical measurements were performed on all the existing teeth, except the third molars. The number of remaining teeth and decayed/missing/filled teeth (DMFT) were noted. The plaque levels were recorded using the plaque index of Löe and Silness. The gingival index modified by Löe was used to evaluate gingival inflammation. Teeth mobility was measured using bidigital mobility. The probing pocket depth was measured using a periodontal probe. Periodontal disease was defined as the presence of at least 10 sites with a probing depth ≥5 mm. Student’s t and chi-square tests were used to compare, respectively, the two groups’ quantitative and qualitative data. The two groups were matched for quantities of used tobacco, age, daily toothbrushing frequency, teeth mobility, number of remaining teeth, plaque index, and DMFT. Compared to the ECS group, the ENS group had a significantly lower number of yearly visits to the dentist (mean ± SD: 0.2 ± 0.5 vs. 0.1 ± 0.2), lower probing pocket depth (mean ± SD: 2.33 ± 0.63 vs. 2.02 ± 0.80 mm), and gingival index (median [interquartile]: 0.46 [0.10–0.89] vs. 0.00 [0.00–0.50]), and it included significantly lower percentages of smokers with periodontal disease (24.3% vs. 9.5%). In conclusion, chronic exclusive narghile smoking has fewer adverse effects on the periodontium than chronic exclusive cigarette smoking.
... Narghile use is frequently associated with several diseases. Hence, numerous studies were published concerning the general effects of narghile use on health (Awan, Siddiqi, Patil, & Hussain, 2017;Ben Saad, 2010;Bou Fakhreddine, Kanj, & Kanj, 2014;Chaouachi, 2015;El-Zaatari, Chami, & Zaatari, 2015;Waziry, Jawad, Ballout, Al Akel, & Akl, 2017;WHO, 2005WHO, , 2015. As inhalation of the toxic substances included in narghile smoke may affect the integrity of the oral cavity (Amer, Waguih, & El-Rouby, 2019) and as dentists may have narghile smokers as their patients, it is fundamental [AQ: 5] to inform them of the significantly damaging impacts of its use on some components of the oral cavity, such as the periodontium. ...
... Persson, Bergström, Gustafsson, & Asman, 1999;Ryder, 1994;Ryder et al., 1998). However, since the toxic substances and the chemical profile of narghile smoke are completely different from those of cigarettes (e.g., the mean blood nicotine level in ENSs sitting for a narghile session [~45 min] was lower than that identified in ENSs having smoked 1 cigarette [~5 min] or corresponding to that of 1.7 cigarette when applying a pharmacokinetics model; Ben Saad, 2009;Chaouachi, 2009Chaouachi, , 2015Eissenberg & Shihadeh, 2009;Primack et al., 2016), these two methods of tobacco smoking are hypothesized to induce different health effects in ENSs and ECSs. For instance, one Tunisian study concluded that narghile smoking has less adverse effects on pulmonary function tests than cigarette smoking (Ben Saad, Khemiss, Nhari, Ben Essghaier, & Rouatbi, 2013). ...
Article
Full-text available
Studies evaluating the effects of narghile-use on the periodontium present conflicting conclusions. This study aimed to compare the periodontal status in ENSs (n=74) and ECSs (n=74). Males aged 20-40 Yrs were recruited to participate in this comparative study. Information concerning oral health habits [number of yearly visits to the dentist, daily tooth-brushing frequency] and tobacco exposure were obtained. Clinical measurements were performed on all the existing teeth, except the third molars. The remaining teeth and the decayed missing filled teeth (DMFT) were noted. The plaque-levels were recorded using the plaque-index of Loe and Silness. The gingival-index modified by Loe was used to evaluate gingival inflammation. Teeth mobility was measured using bidigital mobility. The probing pocket depth was measured using a periodontal probe. Periodontal disease was defined as the presence of at least 10 sites with a probing depth ≥ 5 mm. Student’s t and Chi-square tests were used to compare, respectively, the two groups’ quantitative and qualitative data. The two groups were matched for quantities of used tobacco, age, daily tooth-brushing frequency, teeth mobility, remaining teeth, plaque-index and DMFT. Compared to the ECSs group, the ENSs group had a significantly lower number of yearly visits to the dentist [means±SD:0.2±0.5 vs. 0.1±0.2; respectively], lower probing pocket depth [means±SD:2.33±0.63 vs. 2.02±0.80 mm; respectively], gingival-index [medians (interquartile):0.46(0.10-0.89) vs. 0.00(0.00-0.50); respectively], and it included significantly lower percentages of smokers with periodontal disease [24.3 vs. 9.5%; respectively]. In conclusion, chronic exclusive narghile smoking has less adverse effects on the periodontium than chronic exclusive cigarette smoking
... Cigarette smoking is a well-known danger to health and executes roughly 6 million individuals every year (WHO, 2017). Shisha has been known as a common technique for tobacco smoking in the Middle East, the Indian subcontinent and worldwide for quite a few years (Mirahmadizadeh A & Nakhaee N., 2008;Chaouachi K., 2009Chaouachi K., & 2015. Researchers have claimed that the prevalence of shisha smoking in the Eastern Mediterranean Region is the highest in the world, ranging between 20% and 70% (Haddad L, Kelly DL, Weglicki LS, et al., 2016). ...
Article
Full-text available
Shisha smoking is a common method of tobacco smoking in the Mediterranean Region with prevalence ranging between 20% and 70%. Actually, shisha smoking is becoming increasingly popular method of tobacco smoking worldwide. Pain is a subjective experience influenced by genetic, developmental, familial, psychological, social and cultural variables. An increase in pain tolerance threshold (Ptt) ,which is defined as the highest intensity of painful stimulation that a tested subject is able to tolerate, was noticed with cigarette smoking. However, the relation between shisha smoking and pain detection threshold (Pdt), defined as the lowest intensity of a painful stimulus at which the subject perceives pain and pain tolerance threshold (Ptt) has not been studied. The purpose of this study was to determine the association between Pdt and Ptt in shisha smokers in Lebanon. A total of 400 participants from different areas in Lebanon were recruited of which 216 were non-smokers and 184 were shisha-smokers. The sphygmomanometer cuff technique was used to detect Pdt and Ptt. As a result, the mean age of these participants was 27.46 years (standard deviation=11.79). Shisha-smoker male participants represented 53.7% while female shisha-smokers presented 40.8%. Pdt and Ptt were significantly greater in shisha smokers than in non-smokers with P = 0.001 and P < 0.001 respectively. The mean number of heads of shisha smoked was 2.64 heads (standard deviation = 4.70). Both Pdt and Ptt are significantly increased in shisha smokers who smokes more heads of shisha per day with a p value of 0.031 and 0.002 respectively. However, in shisha smokers, the mean number of shisha smoking years was 2.68years (standard deviation = 5.22). Only Ptt significantly increased (P = 0.007) with more smoking years Moreover, Pdt and Ptt were both significantly higher (P < 0.001) in males than in females. One may conclude that shisha smokers have higher tolerance thresholds for pain than non-smokers.
... 4 The reality is far from it as it contains the same harmful substances such as nicotine, carcinogens, hydrocarbons, tar and heavy metal. 5 An average pipe smoking session lasts longer hence larger volume of smoke inhaled compare to a single cigarette. 6 Some researches suggest people who are into pipe smoking also pursue other forms of intoxications like drugs and alcohol. ...
... Consumers are lured and addicted to this smoking device by the variety of flavored tobacco [3,4] available on the market. There are misconceptions among waterpipe consumers that bubbling the generated smoke through water before lung inhalation can remove all if not most of the harmful components [5,6]. These misconceptions together with cheap prices of the waterpipe smoking apparatus and the sweetened flavored tobacco itself led to a consumption epidemic [6]. ...
Article
Waterpipe smoking is a popular pastime worldwide with statistics pointing to an alarming increase in consumption. In the current paper, the evaluation of sub-chronic waterpipe smoke exposure was undertaken using C57BL/6 female mice using a dynamic exposure setting to emulate smoke exposure. Mice were daily subjected to either one (single exposure, SE) or two sessions (double exposure, DE) of waterpipe-generated smoke (two-apple flavor) for a period of two months. Although lungs histopathological examination pointed to a minor inflammation in smoke-exposed mice compared to control air-exposed (CON) group, the lung weights of the waterpipe-exposed mice were significantly higher (+72% in SE and +39% in DE) (p < 0.01) when compared to CON group. Moreover, changes in the protein expression of several proteins such as iNOS and JNK were noted in the lungs of smoke-exposed mice. However, no changes in p38 and EGFR protein levels were noted between the three groups of mice. Our results mainly show a significant increase in urea serum levels (+28%) in SE mice along with renal pathological damage in both SE and DE mice compared to CON. Additionally, severe significant DNA damages (p < 0.05) were reported in the lungs, kidneys, bone marrow and liver of waterpipe-exposed animals, using MTS and COMET assays. These findings highlight the significant risks posed by sub-chronic waterpipe smoke exposure in the selected animal model and the pressing need for future better management of waterpipe indoor consumption.
... WTS is also associated with ischemic heart diseases, and hypertension. 1,4 Similarly, WTS affects airway diseases. Several studies have confirmed the harmful effect of WTS on the lungs causing bronchitis and/or chronic obstructive pulmonary diseases (COPD) and enhancing asthma susceptibility and exacerbations. ...
Article
Full-text available
Waterpipe tobacco smoking (WTS) is increasingly popular among young people. Although perceived to be safer than cigarettes as smoke is filtered through water, narghile smoke is rich in carbon monoxide, as well as containing numerous toxins and carcinogens. Detrimental effects of WTS may include nicotine addiction, bronchitis, chronic obstructive pulmonary diseases and enhancing asthma susceptibility and exacerbations.
... Any standard method adopted for laboratory testing purposes will involve a high degree of idealization of real-time use patterns. As with the tobacco industry's decades-long effort to undercut tobacco control policy by creating scientific controversy [24], uncertainties deriving from the use of standardized testing methods have been exploited to sow doubt about the harmful nature of waterpipe smoke [25]. ...
Article
Background Studies that assess waterpipe tobacco smoking behaviour and toxicant exposure generally use controlled laboratory environments with small samples that may not fully capture real-world variability in human behaviour and waterpipe products. This study aimed to conduct real-time sampling of waterpipe tobacco use in natural environments using an in situ device. Methods We used the REALTIME sampling instrument: a validated, portable, self-powered device designed to sample automatically a fixed percentage of the aerosol flowing through the waterpipe mouthpiece during every puff. We recruited participants at café and home settings in Jordan and measured puffing behaviour in addition to inhalation exposure of total particulate matter (TPM), carbon monoxide (CO), nicotine, polycyclic aromatic hydrocarbons and volatile aldehydes. We correlated total inhaled volume with five selected toxicants and calculated the regression line of this relationship. Results Averaged across 79 singleton sessions (52% male, mean age 27.0, 95% home sessions), sessions lasted 46.9 min and participants drew 290 puffs and inhaled 214 L per session. Mean quantities of inhaled toxicants per session were 1910 mg TPM, 259 mg CO, 5.0 mg nicotine, 117 ng benzo[a]pyrene and 198 ng formaldehyde. We found positive correlations between total inhaled volume and TPM (r=0.472; p<0.001), CO (r=0.751; p<0.001), nicotine (r=0.301, p=0.035) and formaldehyde (r=0.526; p<0.001), but a non-significant correlation for benzo[a]pyrene (r=0.289; p=0.056). Conclusions In the natural environment, waterpipe tobacco users inhale large quantities of toxicants that induce tobacco-related disease, including cancer. Toxicant content per waterpipe session is at least equal, but for many toxicants several magnitudes of order higher, than that of a cigarette. Health warnings based on early controlled laboratory studies were well founded; if anything our findings suggest a greater exposure risk.
Article
Full-text available
Objective We investigated the effects of chronic waterpipe (WP) smoke on pulmonary function and immune response in a murine model using a research-grade WP and the effects of acute exposure on the regulation of immediate-early genes (IEGs). Methods WP smoke was generated using three WP smoke puffing regimens based on the Beirut regimen. WP smoke samples generated under these puffing regimens were quantified for nicotine concentration. Mice were chronically exposed for 6 months followed by assessment of pulmonary function and airway inflammation. Transcriptomic analysis using RNAseq was conducted after acute exposure to characterise the IEG response. These biomarkers were then compared with those generated after exposure to dry smoke (without water added to the WP bowl). Results We determined that nicotine composition in WP smoke ranged from 0.4 to 2.5 mg per puffing session. The lung immune response was sensitive to the incremental severity of chronic exposure, with modest decreases in airway inflammatory cells and chemokine levels compared with air-exposed controls. Pulmonary function was unmodified by chronic WP exposure. Acute WP exposure was found to activate the immune response and identified known and novel IEG as potential biomarkers of WP exposure. Conclusion Chronic exposure to WP smoke leads to immune suppression without significant changes to pulmonary function. Transcriptomic analysis of the lung after acute exposure to WP smoke showed activation of the immune response and revealed IEGs that are common to WP and dry smoke, as well as pools of IEGs unique to each exposure, identifying potential biomarkers specific to WP exposure.
Article
Full-text available
Objective. To compare the periodontal bone height of exclusive narghile smokers (ENS) with that of exclusive cigarette smokers (ECS). Methods. Tunisian males aged 20-35 years who have been ENS for more than five narghile-years or ECS for more than five pack-years were recruited to participate in this comparative cross-sectional study. Information about oral health habits and tobacco consumption were gathered using a predetermined questionnaire. Plaque levels were recorded on four sites using the plaque index of Loe and Silness. The periodontal bone height was measured mesially and distally from digital panoramic radiographs of each tooth and expressed as a percentage of the root length. A periodontal bone height level ≤0.70 was applied as a cutoff reference value signifying bone loss. Student t-test and Chi2 test were used to compare quantitative and qualitative data of both groups. Results. There were no significant differences between the ENS (n = 60) and ECS (n = 60) groups regarding age and the consumed quantities of tobacco (28 ± 4 vs. 27 ± 5 years, 7 ± 3 narghile-years vs. 8 ± 3 pack-years, respectively). Compared to the ECS group, the ENS group had a significantly higher plaque index (mean ± SD values were 1.54 ± 0.70 vs. 1.84 ± 0.73, respectively). However, the two groups had similar means of periodontal bone height (0.85 ± 0.03 vs. 0.86 ± 0.04) and tooth brushing frequencies (1.1 ± 0.8 vs. 0.9 ± 0.6 a day, respectively) and had similar bone loss frequencies (15% vs. 12%, respectively). Conclusion. Both ENS and ECS exhibited the same periodontal bone height reduction, which means that both types of tobacco smoking are associated with periodontal bone loss.
Article
Full-text available
Background: The potential for emerging tobacco products (ETPs) to be gateway products for further tobacco use among youth is of significant concern. Purpose: To examine use of various nicotine-containing products on a tobacco-free college campus and whether the first product tried predicts subsequent tobacco use. Methods: Undergraduate students (N¼1,304) at a large university completed an online survey of past/current use of cigarettes; smokeless tobacco (SLT); hookah; ETPs (dissolvables, snus, and electronic cigarettes); and nicotine replacement therapy (NRT). Data were collected from September 2012 to May 2013 and analyses were conducted from June to September 2013. Students were classified as single, dual, or poly tobacco users. Results: The sample consisted of 79.5% non-users, 13.8% single, 4.4% dual, and 1.5% poly users. Overall, 49.4% of participants reported trying a tobacco product. Hookah was the most tried product (38%), but cigarettes were most often the first product ever tried (51%). First product tried did not predict current tobacco use and non-use, but individuals who first tried SLT or cigarettes (rather than hookah or ETPs) were more likely to be poly tobacco users. Current tobacco users who first tried ETPs or hookah were largely non-daily users of hookah; current tobacco users who first tried cigarettes or SLT were largely non-daily or daily users of cigarettes/SLT. Conclusions: Hookah and ETPs are increasingly becoming the first tobacco product ever tried by youth; however, uptake of ETPs is poor, unlike cigarettes and SLT, and does not appear to lead to significant daily/non-daily use of cigarettes and SLT. (Am J Prev Med 2015;48(1S1):S86–S93) & 2015 American Journal of Preventive Medicine. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/3.0/).
Article
Full-text available
Cigarette smoking is documented source of human internal intake of toxic trace and heavy metals. However, data about tobacco-derived products such as moassel/tabamel and jurak, used in the growingly popular shisha (narghile, hookah), have been scarce and scattered. In these conditions, the objective of this study, the first ever carried out on this scale, was to investigate the elemental contents of moassel and jurak and compare it with that of other tobacco products. Representative samples from 3 different moassel brands were collected. Concentration of 34 elements was measured using the Inductively Coupled Plasma Mass Spectrometer (ICP-MS). Results show that trace elements are much more abundant in cigarette tobacco than in shisha moassel. A wide range of variations was observed. For instance, the levels of As, Cd and Ni (mg kg-1) were: 1.59, 1.0 and 0.146; 1.45, 0.5 and 0.075; 3.5, 5 and 0.63; for, respectively: cigarette, moassel and jurak. Since shisha smoking is continuously targeted by antismoking groups as a “global epidemic”, a public health priority should be the design of culturally tailored products (for instance resins prepared from local plants to be mixed with the water of the pipes) based on well-established harm reduction techniques. Keywords: hookah; narghile; shisha; tobacco; moassel; tabamel; molasses; smoking; trace elements; heavy metals; dose assessment Note: [Full version to be republished soon, with new DOI]
Article
Full-text available
Waterpipe tobacco smoking (WTS) involves passing tobacco smoke through water prior to inhalation, and has spread worldwide. This spread becomes a public health concern if it is associated with tobacco-caused disease and if WTS supports tobacco/nicotine dependence. A growing literature demonstrates that WTS is associated with disability, disease and death. This narrative review examines if WTS supports nicotine/tobacco dependence, and is intended to help guide tobacco control efforts worldwide. PUBMED search using: (("waterpipe" or "narghile" or "arghile" or "shisha" or "goza" or "narkeela" or "hookah" or "hubble bubble")) AND ("dependence" or "addiction"). Excluded were articles not in English, without original data, and that were not topic-related. Thirty-two articles were included with others identified by inspecting reference lists and other sources. WTS and the delivery of the dependence-producing drug nicotine were examined, and then the extent to which the articles addressed WTS-induced nicotine/dependence explicitly, as well as implicitly with reference to criteria for dependence outlined by the WHO. WTS supports nicotine/tobacco dependence because it is associated with nicotine delivery, and because some smokers experience withdrawal when they abstain from waterpipe, alter their behaviour in order to access a waterpipe and have difficulty quitting, even when motivated to do so. There is a strong need to support research investigating measurement of WTS-induced tobacco dependence, to inform the public of the risks of WTS, which include dependence, disability, disease and death, and to include WTS in the same public health policies that address tobacco cigarettes. Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://group.bmj.com/group/rights-licensing/permissions.
Article
Full-text available
Introduction: Smoking is known to have physiological effects on biological systems. The purpose of this study is to evaluate acute and chronic effects on pulmonary functions and cardiovascular indices of waterpipe (WP) smoking in real life circumstances. Methods: Three groups were included in the study: non-smokers (N = 42), WP smokers (N = 42) and cigarette smokers (N = 48). A questionnaire was completed for each participant, in addition to pulmonary function [forced expiratory volume at 1 s (FEV1), 6 s (FEV6), percentage of FEV1/FEV6], and cardiovascular [diastolic blood pressure (DBP), systolic blood pressure (SBP) and heart rate (HR)] measures, taken before and after smoking. Results: Mean values of FEV1, FEV6, FEV1/FEV6, DBP and SBP in WP and cigarette smokers were very close. However, WP smoking significantly increased HR compared to cigarette smokers (p = 0.007); duration of smoking, age at first WP and quantity of smoking affected pulmonary function and cardiovascular values. In the subgroup of WP smokers, DBP was acutely increased by a larger WP size (p = 0.011), while the FEV6 was acutely increased by a smaller WP size (p = 0.045). Conclusion: WP smoking affected the cardiovascular system more than cigarette smoking, while it had similar effects on pulmonary function.
Article
Full-text available
Background Tobacco smoking is the main health-care problem in the world. Evaluation of scientific output in the field of tobacco use has been poorly explored in Middle Eastern Arab (MEA) countries to date, and there are few internationally published reports on research activity in tobacco use. The main objectives of this study were to analyse the research output originating from 13 MEA countries on tobacco fields and to examine the authorship pattern and the citations retrieved from the Scopus database. Methods Data from 1 January 2003 through 31 December 2012 were searched for documents with specific words regarding the tobacco field as 'keywords’ in the title in any 1 of the 13 MEA countries. Research productivity was evaluated based on a methodology developed and used in other bibliometric studies. Results Five hundred documents were retrieved from 320 peer-reviewed journals. The greatest amount of research activity was from Egypt (25.4%), followed by the Kingdom of Saudi Arabia (KSA) (23.2%), Lebanon (16.3%), and Jordan (14.8%). The total number of citations for the 560 documents, at the time of data analysis (27 August 2013), was 5,585, with a mean ± SD of 9.95 ± 22.64 and a median (interquartile range) of 3(1–10). The h-index of the retrieved documents was 34. This study identified 232 (41.4%) documents from 53 countries in MEA-foreign country collaborations. By region, MEA collaborated most often with countries in the Americas (29.6%), followed by countries in the same MEA region (13.4%), especially KSA and Egypt. Conclusions The present data reveal a promising rise and a good start for research productivity in the tobacco field in the Arab world. Research output is low in some countries, which can be improved by investing in more international and national collaborative research projects in the field of tobacco.
Article
The use of the waterpipe, a traditional aid for the consumption of tobacco, has spread worldwide and is steadily increasing especially among the youth. On the other hand, there is a lack of knowledge regarding the composition of mainstream waterpipe smoke and the toxicological risks associated with this kind of smoking habit. Using a standardized machine smoking protocol, mainstream waterpipe smoke was generated and further analyzed for twelve volatile organic compounds (VOCs) and eight phenolic compounds by applying gas chromatography-mass spectrometry and reverse-phase high-performance liquid chromatography-fluorescence detection, respectively. Additionally, seventeen elements were analyzed in waterpipe tobacco and charcoal prior to and after smoking, applying inductively coupled plasma-mass spectrometry to assess the maximum exposure of these elements. For the first time ever, we have been able to show that waterpipe mainstream smoke contains high levels of the human carcinogen benzene. Compared with cigarette smoke yields, the levels were 6.2-fold higher, thus representing a significant health hazard for the waterpipe smoker. Furthermore, we found that waterpipe mainstream smoke contains considerable amounts of catechol, hydroquinone and phenol, each of which causing some health concern at least. The analysis of waterpipe tobacco and charcoal revealed that both matrices contained considerable amounts of the toxic elements nickel, cadmium, lead and chromium. Altogether, the data on VOCs, phenols and elements presented in this study clearly point to the health hazards associated with the consumption of tobacco using waterpipes.