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JJBS
Volume 4, Number 4, December 2011
ISSN 1995-6673
Pages 219 - 224
Jordan Journal of Biological Sciences
Histological Changes in Tissues of Trachea and Lung Alveoli of
Albino Rats Exposed to the Smoke of Two Types of Narghile
Tobacco Products
Ziad A. Shraideh* and Hossam N. Najjar
Department of Biological Sciences, University of Jordan, Amman, Jordan
Received 11 April 2011; received in revised form 28 June 2011; accepted 30 June 2011
Abstract
Undoubtedly, narghile smoking has become a common social practice in the Arab region, and a growing phenomenon in the
whole world. This study is an attempt to reveal the effects of narghile smoking on the cellular level, through exposing a group
of experimental albino rats to the smoke of two types of narghile tobacco-derived products: flavored (moassal) and
unflavored (tumbak), for three months on a daily basis, using a specially designed smoking machine. The most prominent
histological changes were an abnormal proliferation in the epithelium of trachea, disruption of its cilia, and a marked
hyperplasia in the connective tissue of lung alveoli. Finally, further research should be done to give definitive conclusions
about the product with an overall stronger effect. However, based on our experiment, smokers could be advised not to smoke
on a daily basis and in poorly ventilated areas.
Keywords: Narghile smoking, trachea, lung alveoli, moassal, tumbak, cilia.
1. Introduction *
Water-pipe (narghile) is a generic name which refers to
any apparatus involves the passage of smoke through
water before inhalation (Al-Safi et al., 2009). Water-pipe
smoking is currently considered a fashionable way of
tobacco leaves consumption, especially among the present-
day water-pipe smokers including trendy youth, university
students, and even high-school-aged children, although it
used to be as a pleasurable pastime of older and retired
people (Onder et al., 2002; Knishkowy and Amitai, 2005;
Neergaard et al., 2007).
Primarily, there are two types of narghile tobacco
products: the flavored one which could be either moassal
(also known as tobamel) or jurak, and the unflavored type,
called tumbak (or ajamy). Both types are tobacco-based;
the flavored type contains lesser amount of tobacco than
tumbak. Tumbak is the one that is purely made of
moistened shredded tobacco leaves, usually soaked in
water before being squeezed and packed in the bowl of the
narghile (Chaouachi, 2009). In addition to tobacco,
moassal contains molasses, honey, or other syrups,
together with glycerol, and flavoring essences (Chaouachi,
2009; Chaouachi, 2010).
Upon passing over the charcoal and through the tobacco,
the heated air becomes loaded with the combustion
products of charcoal, as well as a variety of products from
the heated tobacco, forming the mainstream smoke (MSS)
aerosol, that consists of both gaseous and suspended
particles in the form of liquid droplets, containing a wide
* Corresponding author: zshraideh@ju.edu.jo
variety of condensed organic compounds (Knishkowy and
Amitai, 2005). Then, the smoke will bubble into the water
jar, being cooled and diluted there, and finally a post-
bubbling MSS is carried through the hose to the smoker
(Knishkowy and Amitai, 2005).
Although a number of adverse health consequences
have been epidemiologically associated with the use of
narghile smoking as heart disease and oral cancer, other
fields of research, especially histopathology is very
limited (Akl et
al., 2010). However, most of the
corresponding studies were led in the past decades, and the
authors of recent reviews have not realized that the
products were either not detailed or not the one of growing
concern (flavored moassal with a certain type of charcoal
(quicklighting). This has resulted in a growing global
confusion, including in meta-analysis (Chaouachi, 2011;
Neergaard et al., 2007).
Hence, among the scarcity of histopathological
research about narghile smoking, this study may increase
the public concern about the narghile use, hoping it would
help to uncover the negative face of this smoking method,
through revealing the potential adverse effects of narghile
smoke from two tobacco products, that differed principally
in their components, on some histological parameters, that
weren't highlighted by literature on selected tissues in an
animal model (albino rat).
2. Materials and Methods
2.1. Experimental animals
Wistar albino male rats, Rattus norvegicus, with an
average weight 215±2.5g were used. The animals were
obtained from the University of Jordan colony and
© 2011Jordan Journal of Biological Sciences. All rights reserved - Volume 4, Number 4
220
maintained under optimal conditions including diet and
temperature.
2.2. Histological study design
This study is based on the chronic exposure of thirty
experimental albino rats to the post-bubbling narghile
MSS, coming from the complete heating/burning of 20 g
from one of either two different narghile tobacco products:
moassal or tumbak, for a period of 3 months, one session a
day. An automated smoking machine as discussed in
(Shraideh et al., 2011) was used to expose the rats to
narghile MSS. Each cycle of the smoking regimen lasts for
90 seconds and consists of three successive steps,
operating as follows: Narghile smoke is drawn through the
inhalation chamber continuously for 30 sec. An inlet to
fresh air is then opened, allowing fresh air to be introduced
instead of smoke, which will be washed out of the
chamber. The washing out process will also take 30 sec. In
the last 30 sec, the vacuum pump will be turned off, and
rats will be allowed to breathe fresh air, normally
(Shraideh et al., 2011).
Narghile water was changed, and the tube was cleaned
with distilled water after every experiment.
Albino rats were divided into 3 equal groups. The first
group was the air-exposed control one, the second contains
rats that have been exposed to moassal smoke, and the
third group exposed to tumbak smoke. Following the
exposure period, a histological examination by light
microscopy of tissue pieces from the middle of tracheal
segments and the anterior aspect of the right middle lobe
of lung tissue was done. For each type of tobacco product,
tissue pieces were taken from three randomly-selected
albino rats.
2.2.1. Protocol of light microscopy
After overnight recovery from the last smoke
exposure, rats were sacrificed by ether anaesthesia, and
tissues of trachea and lung alveoli were gently dissected
out, washed well with normal saline (0.9% NaCl), and
fixed in 10% salined formalin. Using an automated tissue
processor, tissues were fixed, dehydrated, cleared, and
finally infiltrated by a hot liquid paraffin wax. To be ready
for sectioning, tissues were embedded in paraffin. A
ribbon of tissue sections were then obtained on a manual
rotary microtome (Spencer 50) at 5 µm thickness. Two
baths of 30% ethanol and a hot tap water were used to
overcome the folding tendency. Thereafter, tissue sections
were loaded on a glass slide meshed with egg albumin,
dried, stained with classical haematoxylin and eosin stain
(H&E), and finally mounted using Distyrene, Plasticizer,
and Xylene (D.P.X.) mountant.
3. Results
3.1. Effect on the trachea
Control sections showed healthy ciliated
pseudostratified columnar epithelium, mucosal and
fibroelastic layers normally seen in tracheal tissue (Figure.
1(.
3.2. Moassal smoke-exposed group
The tracheal mucosa of this group was adversely
affected; showing an increase in the number of epithelial
cells, amalgamation of cilia, presence of inclusion bodies,
and lymphocytic infiltration (Figure. 2).
3.3. Tumbak smoke-exposed group
Profound epithelial cell proliferation and lymphocytic
infiltration were observed in tracheal sections of this
group. Cilia were either amalgamated or almost lost in
other sections (Figure. 3).
3.4. Effect on alveoli of the lung
Photomicrographs of lung alveoli from control animals
revealed the normal appearance of their characteristic
simple squamous epithelium (Figure. 4).
3.5. Moassal smoke-exposed group
Lung alveoli of this group showed clear thickening in
the connective tissue, and lymphocytic infiltration (Figure.
5).
3.6. Tumbak smoke-exposed group
Lung alveoli of this group showed areas with profound
thickening in the connective tissue (Figure. 6).
Figure 1. Section of normal tracheal tissue. CPCE: ciliated pseudostratified columnar epithelium, C: cilia, BM: basement membrane, BC:
basal cell. H&E stain.
© 2011Jordan Journal of Biological Sciences. All rights reserved - Volume 4, Number 4
221
Figure 2. Section from the tracheal mucosa of moassal smoke-exposed rat, showing an increase in the number of epithelial cells, and
lymphocytic infiltration (triangles). IB: inclusion body, AC: amalgamated cilia, GC: goblet cell. Triangles indicate lymphocytes. H&E stain.
Figure 3. Trachea of tumbak smoke-exposed rat. The thick arrow indicates an area where the epithelium was disrupted. The thin arrow
indicates a profound loss of the cilia. Epithelial cells are highly proliferated. H&E stain.
Figure 4. Control lung alveoli. IAS: interalveolar septum, C: capillary. H&E stain.
Figure 5. Lung alveoli of moassal smoke-exposed rat. Thin arrows denote areas with obvious alveolar wall thickening. The thick arrow
indicates a lymphocytic cell. H&E stain.
© 2011Jordan Journal of Biological Sciences. All rights reserved - Volume 4, Number 4
222
Figure 6 Lung alveoli of tumbak smoke-exposed rat. The arrows indicate obvious alveolar disruption. H&E stain.
4. Discussion
Cells of trachea and lung alveoli showed an adaptation
by altering their pattern of growth, resulting in a
hyperplasia. However, the limit of this adaptive response
was exceeded, resulting in cell injury, which may be due to
an oxidative stress; following the statement by (Ben Saad
et al., 2010), that oxidative stress was increased
significantly by regular water-pipe smoking, and the
observation by (Sharma et al., 1997) of the presence of
elevated levels of free radicals in peripheral blood
neutrophils of water-pipe smokers. However, further
support to the occurrence of oxidative stress associated
with water-pipe smoking, which can lead to an imbalance
in the production/ consumption level of reactive oxgyen
species (ROS), would come from the following two
studies: The first study, done by )Al-Numair et al.,
2007(,showed a significant increase in malondialdehyde -a
biomarker for oxidative stress-, and a significant decrease
in vitamin C - a potent antioxidant- in water-pipe
smokers. The second study, done by) Wolfram et al.,
2003), investigated the potential effect of smoking narghile
on oxidation injury, by monitoring parameters of the (iso)
eicosanoid system in narghile smokers. Two biomarkers of
in vivo oxidative stress: 8-Epi-prostaglandin F2 alpha (8-
epi-PGF2 alpha) and malondialdehyde were significantly
increased after a single smoking session, and that repeated
daily smoking induced a persistent long-lasting oxidation
injury.Based on these facts, the following discussion is
actually revealing the degree of cellular injury in two of
the primary routes for smoke exposure (trachea and alveoli
of the lung).
Trachea: The obvious disruption of the tracheal
epithelium occurred by exposure to either moassal or
tumbak smoke which caused powerful epithelial damage;
will paralyze the cilia, enabling harmful foreign particles
as dust or bacteria to remain in contact with the respiratory
membranes for a prolonged periods, easily reach the
lamina propria, where they can invade blood capillaries or
lymphatic vessels, increasing the risk of toxic damage.
Cracks that frequently observed within the tracheal
epithelium are due to cell degeneration.
Ciliary amalgamation that can be viewed as part of
epithelial disruption, may result from the hyperplasia of
mucus-secreting submucosal glands, and may affect the
airway clearance mechanisms. Inclusion bodies were
observed, and they referred to any small amorphous
blackish aggregate of smoke toxicants, primarily tar
components.
The observed loss of cilia especially in tumbak-treated
sections may be related to the high degree of nicotine it
contains, through its effect on microtubules;
polymerization / depolymerization of tubulin (Zenzes and
Bielecki, 2004). Acetaldehyde and acrolein are suspected
to play a role in the damage of cilia. Acetaldehyde was
able to impair the ciliary function and beat frequency, by
inhibiting ciliary dynein ATPase activity, and binding to
ciliary proteins critical in the functioning of dynein and
tubulin, whereas acrolein was found to adversely perturb
the cilia by reducing its beat frequency, in cultured bovine
bronchial epithelial cells (Dye and Adler, 1994).
Alveoli of the lung: Concerning the layers of cells lining
the alveoli and the surrounding capillaries, are each only
one cell thick, and are in very close contact with each other
to facilitate gas diffusion between them; it is expected that
the prominent thickening of the alveolar wall (pulmonary
hyperplasia and hypertrophy) will compromise its capacity
for gaseous exchange, resulting in a reduced gas transfer.
According to the presence of extravasated erythrocytes, it
could be simply justified by vascular injury.
Lymphocytic infiltration may mediate the occurrence of
inflammation. However, lymphocytes together with other
inflammatory cells are frequently found in the
bronchoalveolar lavage (BAL) of narghile smokers. For
instance, Ourari, et al. (2006), have compared the cytology
of the bronchoalveolar lavage BAL fluid (macrophages,
lymphocytes, neutrophiles, and eosinophiles), and the lung
function in 30 narghile users and 10 cigarette smokers.
Researchers found that regular use of narghile induces a
rise in the overall cell number in BAL. The increase does
not seem to bring about significant changes in a number of
lung function parameters when compared to cigarettes.
The FEV1 and lung capacity were significantly higher.
These results were also reported in the comprehensive
critical review drawn by (Ben Saad et al., 2010).
5. Conclusion
No definitive conclusions can be drawn because, first,
it is only an animal experimentation; second, it is based on
exposing animals to smoke in a closed chamber. However,
based on this experiment, smokers could be advised not to
smoke on a daily basis and in poorly ventilated areas.
Regarding the smoking machine, we can suggest that the
method of smoke exposure should be improved in a future study
based on the same machine, but it could be set with different
© 2011Jordan Journal of Biological Sciences. All rights reserved - Volume 4, Number 4
223
parameters (for instance reducing puffing period, even if the
animals may be exposed to a longer duration).
Acknowledgment
This work was supported by a grant from the Deanship
of Scientific Research/ The University of Jordan (Grant
number 1121/2007).
References
Akl A, Gaddam S, Gunukula S, Honeine R, Abou Jaoude P and
Irani J. 2010. The effects of waterpipe tobacco smoking on health
outcomes: a systematic review. Inter J of Epidemiol, 39(3): 834-
857.
Al-Numair K, Barber-Heidal K, Al-Assaf A and El-Desoky G.
2007. Water-pipe (shisha) smoking influences total antioxidant
capacity and oxidative stress of healthy Saudi males. Inter J of
Food, Agri and Environ, 5:17-22.
Al-Safi S, Ayoub N, Albalas M, Al-Doghim I and Aboul-Enein F.
2009. Does shisha smoking affect blood pressure and heart rate. J
of Public Health, 17:121-126.
Ben Saad H. 2010. The narghile and its effects on health. Part II:
The effects of the narghile on health. Rev of Pneumology Clinic,
66(2):132-44.
Ben Saad H, Babba M, Boukamcha, R, Latiri I, Knani J, Slama,
R, Bougmiza, I, Zbidi, A and Tabka, Z. 2010. Submaximal
exercise capacity and quality of life in exclusive water-pipe
smokers. Rev of Respiratory Dis.,, 27(5): 489-495.
Chaouachi K. 2009. Hookah (Shisha, Narghile) smoking and
environmental tobacco smoke (ETS), a critical review of the
relevant literature and the public health consequences. Inter J of
Environ Res and Public Health, 6:798-843.
Chaouachi K. 2011. More Rigor Needed in Systematic Reviews
on “Waterpipe” (Hookah, Narghile, Shisha) Smoking. Chest,
139(5): 1250-1251.
Chaouachi K. 2010. Public health intervention for narghile
(hookah, shisha) use requires a radical critique of the related
“standardized” smoking machine. J of Public Health, 18:69-73.
Dye J and Adler K. 1994. Effects of cigarette smoke on epithelial
cells of the respiratory tract. Thorax, 49: 825-834.
Knishkowy B and Amitai Y.2005. Water-Pipe (Narghile)
smoking: An emerging health risk behavior. Pediatrics, 116:113-
119.
Neergaard J, Singh P, Job J and Montgomery S. 2007. Waterpipe
smoking and nicotine exposure: a review of the current evidence.
Nicotine and Tobacco Res, 9(10):987-994.
Onder M, Oztas M and Arnavut O. 2002. Nargile (Hubble-
Bubble) smoking-induced hand eczema. Inter J of Dermatol,
41:771-772.
Ourari B, Zouaoui A, Mehiri N, Cherif J, Khalsi S, Enaifer E,
Daghfous J, Ionzir B, Boubaker S and Beji M. 2006. Lung cell
profile and lung function in narghile smokers. Rev of Respiratory
Dis., 86(23): 116-122.
Sharma R, Deva C and Behera D. 1997. Reactive oxygen species
formation in peripheral blood neutrophils in different types of
smokers. Indian J of Medical Res, 106:475-480.
Shraideh Z, Awaida W, Najjar H and Musleh M. 2011. A
modified smoking machine for monitoring the effect of tobacco
smoke on albino rats. Jordan J of Biol Sci, 4(2): 109-112.
Wolfram RM, Chehne F, Oguogho A and Sinzinger H. 2003.
Narghile (water pipe) smoking influences platelet function and
(iso-)eicosanoids. Life Sci, 74:47-53.
Zenzes M and Bielecki R. 2004. Nicotine-induced disturbances
of meiotic maturation in cultured mouse oocytes: Alterations of
spindle integrity and chromosome alignment. Tobacco Induced
Dis, 2(3):151-161.
