Narghile, or water-pipe smoking (WPS), has been practiced extensively for ∼400 years. It is common in the Arabian Peninsula, Turkey, India, Pakistan, and other countries. In recent years, there has been a revival of WPS, notably among youth. Most US health professionals are unfamiliar with the practice and health consequences of WPS. Therefore, this trend presents a new challenge for adolescent health care providers. The composition of the tobacco used in WPS is variable and not well standardized. Studies that have examined narghile smokers and the aerosol of narghile smoke have reported high concentrations of carbon monoxide, nicotine, “tar,” and heavy metals. These concentrations were as high or higher than those among cigarette smokers. The few scientific data regarding the adverse health consequences of WPS point to dangers that are similar to those associated with cigarette smoking: malignancy, impaired pulmonary function, low birth weight, and others. Additional dangers not encountered with cigarette smoking are infectious diseases resulting from pipe sharing and the frequent addition of alcohol or psychoactive drugs to the tobacco. Public health strategies for controlling the emerging epidemic of WPS include carrying out epidemiologic and toxicologic research; implementation of laws to limit acquisition and use; and health education, targeting adolescents in particular.
Comments
The absence of dental stains, heat and �smoker�s smell� encourages Waterpipe Smoking
The absence of dental stains [1] and heat in WPS may create a sense of false security which may be exploited commercially. The lack of dental stains and the typical ‘smoker’s smell’ may encourage adolescents to indulge in waterpipe smoking without the knowledge of parents. Until waterpipe users’ exposure to toxic smoke constituents are determined conclusively, WPS should be referred to as a separate harmful entity rather than to its relative safety, if any.
Reference
1.Waterpipe Smoking and Dental Stains-Adding fuel to the controversy?” Sebastian Thomas, et al. (24 July 2007) e letter published in response to
Maziak W, Ward KD, Afifi Soweid RA, et al. Tobacco smoking using a waterpipe: a re-emerging strain in a global epidemic. Tob Control. 2004;13:327-333.
Conflict of Interest:
None declared
Re: Conflict of Interest on the part of K CHAOUACHI
Dear Editor,
I confirm that I had absolutely NO competing interest by the day (15 August 2005) I sent my P3R (Peer-Rewiewed Post Publication) to your journal (Pediatrics) simply because I actually signed away my “rights” -as a co-“inventor” of the patent in question- on the 15th of June 2005, i.e. 2 months before the P3R was out.
Therefore, the statement that the P3R “by Dr. Chaouachi was made within the period potentially affected by this conflict of interest” is absolutely FALSE. This was made clear in my e-mail (April 5, 2007) to Pr Chapman, Editor of the Tobacco Control journal and I can provide any party with a copy of the relevant part of the agreement signed in presence of a State Attorney.
As for the facts concerning a previous so-called “competing interest” with the above journal (for obvious reasons, an objective discussion in Pediatrics, instead of Tobacco Control, is irrelevant here), my self-explanatory E-Letter (dated 17 March 2007) to the Editor of the latter contained all the necessary details but was NOT published. Instead, only excerpts were selected by him for a quite personal interpretation of a complex situation. For instance, and just to take one example, a law suit was brought against me by the two other co-inventors.
In these conditions, I demand that these repeated libellous accusations stop immediately and that their protagonists engage, instead, in a sound and respectful debate on the ideas put forward in my critiques of the growing number of serious and repeated scientific errors we can find in the studies on shisha (hookah, narghile) smoking [1].
Kamal Chaouachi
Researcher and consultant in tobacco control (Paris)
[1] Chaouachi K. A Critique of the WHO’s TobReg “Advisory Note” entitled: “Waterpipe Tobacco Smoking: Health Effects, Research Needs and Recommended Actions by Regulators”. Journal of Negative Results in Biomedicine 2006 (17 Nov); 5:17. http://www.jnrbm.com/content/5/1/17
Conflict of Interest:
None declared
Conflict of Interest on the part of K CHAOUACHI
I would like to draw attention to the April 4, 2007 response [1] by Simon Chapman, Editor of Tobacco Control, to a similar rapid- publicationvreview submitted by K Chaouachi to that journal [2] in response to another review of WPS [3]. A potential conflict of interest on the part of Dr. Chaouachi was discovered by Dr. Chapman, and Dr. Chaouachi subsequently refused to submit a statement detailing this conflict. The P3R here ([4]) by Dr. Chaouachi was made within the period potentially affected by this conflict of interest.
1. Chapman S. Failure to declare competing interest. http://tc.bmj.com/cgi/eletters/13/4/327 Rapid Response to [2]
2. Chaouachi K. Serious Errors in this Study. http://tc.bmj.com/cgi/eletters/13/4/327 Rapid Response to [3]
3. Maziak W, Ward KD, Afifi Soweid RA, Eissenberg T. Tobacco smoking using a waterpipe: a re-emerging strain in a global epidemic. Tob Control (2004) 13: 327-333
4. Chaouachi K. Errors in this New Review. http://pediatrics.aappublications.org/cgi/eletters/116/1/e113
Conflict of Interest:
None declared
Regrettable lack of scientific methodology in studies on WPS
Dear Sirs,
I have studied with great interest the various opinions expressed in the letters and articles articles submitted and I can only regret the striking lack of scientific methodology througout the debate. This takes the form of : A) obvious strong bias in the selection of sources B) total lack of elementary scientific methodology in the studies C) Careful avoidance of the most obvious fact-based approach : (i.e. the chemistry and mechanics of WPS).
While I have been a narghileh smoker since the 80's, I am quite prepared to recognise FACTUAL evidence of un-perceived dangers. I am not prepared to accept un-warranted extrapolation by strongly biased 'experts'.
The exchange of opinions appears to make only very passing mention of what are probably the core quantitative issues of any impact-assessment on public and individual health.
This leads to amalgamating a huge variety of different situations. A short list of preliminary example, for instance, could include : - additions to and/or treatment of the water, - quality and purity of the tobacco, - age, gender, health status of the subjects, - percentage of the smoking mixture composed of tobacco, - so called 'persian WP vs. egyptian / lebanese WP', - smoking of cannabis and other psychotrops , - natural coal vs. self ingniting coal, - covered vs non covered coals, - smoking history of the subjects, - frequency / duration of the sessions, - quantity of smoke inhaled - etc...
There is little to debate about the general ills of tobacco or any other manner of smoking, but being unwilling or unable to differentiate likely high-impact parameters in one's opinions leads to valueless debate.
A few basic facts may orient future studies or at least avoid gross generalisations :
1) It is a clearly established fact that one of the main sources of carcerogenics and of general nocivity of cigarettes is the paper, which is totally absent from WPS.
2) Pipe and cigar smokers generally do not inhale as large a proportion of the smoke produced. Anecdotal evidence suggest that this is at least as true for WPS.
3) Narghileh 'tobacco', (with the exception of 'persian tobacco'(also called Tumbac in various parts), in fact contains under 50% tobacco(by weight). the rest being fruit molases, honey, fruit rinds etc..
4) There is little consensus on the operating modes of narghileh- smoking, but regional modes do correlate on some fairly general hygiene habits : changing the water with each pipe, changing the mouth-piece for each user, separating the tobacco from the charcoal with pierced foil etc..
5) It may be useful to remind the less scientifically educated members of this debate that nicotine is water-soluble, and that tar in aerosol form will coalesce in cold or tepid water (as can be ascertained by analysing the water thrown out after a session.
6) Any analysis that claims to objectivity must segregate the numerous parameters that are likely to have a bearing on health, and carry out parameter-specific analysis.
While there can be no debate as to the general nocivity of ANY smoking, equating the nefarious health impact _without any quantitative or qualitative demonstration whatsoever_ of a two-pack-a-day smoker with a narghileh smoker can only throw discredit on the bearer of such un- informed and biased opinions.
I relish the opportunity to participate in further discussion, provided the substance of the debate can be based on significant and factual considerations.
Very best
Oliver Clark [email protected]
Conflict of Interest:
None declared
Water Pipe (Narghile) Smoking: Response to letter by Chaouachi
September 13, 2005
To The Editor, Pediatrics:
We would like to respond to the letter by Chaouachi (1) regarding our article, "Water Pipe (Narghile) Smoking: An Emerging Health Risk Behavior" (2). First, our article was not based on the review article on water pipe smoking (WPS) by Maziak, et al (3), which appeared (December, 2004) after we submitted our review to Pediatrics (submitted October 3, 2004, revised December 15, 2004). We became aware of their article during the period of the review process, and cited it in our final manuscript. The two reviews naturally summarize much of the same material, since the number of publications regarding WPS in the medical literature is quite limited. We note that much of the material in our review is based on several other, original research papers written by Maziak and colleagues.
Regarding the quality of published data on the health effects of WPS, we thoroughly agree with Chaouachi’s criticism of many of these studies. For this reason, we specified the type of study design in Table 1 (of 17 clinical studies cited, 2 were case reports, 5 were retrospective, and 4 were case control; only 5 were controlled/clinical studies, and one was prospective) – pointing out to the reader both the limited number of studies performed, and the frequently problematic nature of the methodology. We decided not to discuss the methodological problems of each individual study, but mentioned this in a general way, including “the difficulty in studying the isolated effects of narghile since most of the smokers are also current or past cigarette smokers”.
The issue of adolescents’ adding drugs or alcoholic beverages to the tobacco is based on one reference only (4), cited in the text, and cannot be generalized to other populations.
In a general way, we appreciate Chaouachi’s highlighting the currently inadequate data base regarding the health effects of WPS, as well as his critical assessment of the literature. We hope this discussion will stimulate research that will better describe the risks of WPS in the coming years. Having said that, we must also note that we are facing an epidemic regarding which there will not be sufficient, good scientific data in the near future. The preliminary data that we have summarized suggest that WPS is not a benign habit that adolescents may engage in without concern for their health. We believe that health professionals and the public must become aware of the possible consequences of WPS before the practice becomes even more widespread.
References:
1. Chaouachi K. Letter to Pediatrics - Post-publication
Peer Review, August 15, 2005.
2. Knishkowy B, Amitai Y. Water-pipe (narghile) smoking:
an emerging health risk behavior. Pediatrics
2005;116:e113-9.
3. Maziak W, Ward KD, Afifi Soweid RA, Eissenberg T.
Tobacco smoking using a waterpipe: a re-emerging strain
in a global epidemic. Tobacco Control 2004;13:327-33.
4. Varsano S, Ganz I, Eldor N, Garenkin M. Water-pipe
tobacco smoking among school children in Israel:
frequencies, habits, and attitudes. Harefuah
2003;142:736- 41 (Hebrew).
Sincerely,
Barry Knishkowy, MD, MPH
Yona Amitai, MD, MPH
Dept. of Mother, Child and Adolescent Health
Israel Ministry of Health
Conflict of Interest:
None declared
Errors in this New Review
Dear Editor,
KNISHKOWY and AMITAI's review on water pipe (hookah, shisha, narghile) smoking is obviously based on a previous one, prepared by MAZIAK and alii and published in the Tobacco Control Journal. Unfortunately, the latter contained serious errors that I brought out in a response sent to the same journal and it appears that this has not been taken into account by the authors. Consequently, I feel obliged to emphasise on a certain number of findings to help my colleagues not to wade too much in this field of research.
Under the "MALIGNANCY" heading, one can read:
A survey of 25 men with bronchogenic carcinoma in India found that 22 were narghile smokers.25 A case-control study of 214 Chinese tin miners found a twofold risk for lung cancer among those who had ever used water pipes compared with nonsmokers and a dose-response relation with increasing pipe-year usage.26 WPS was associated with esophageal and gastric carcinoma in a preliminary survey from Yemen.27 A case-control study of bladder cancer patients in Egypt showed no difference in rates between water-pipe smokers and nonsmokers.28 Two cases of squamous cell carcinoma and 1 of keratoacanthoma of the lower lip have been reported among Egyptian narghile smokers.29 These reports suggest that WPS has a carcinogenic role in a number of body systems.
The point is not to discuss all the cited references because most of the volunteers were simultaneous or ex-users of different tobacco (cigarette, bidis, etc.) products or other substances. The example of Yemen is particularly striking for any specialist of this country because of the well known common use of qat.
The findings of the corresponding studies cannot be relevantly exploited because very often one cannot clarify if the committed volunteers were exclusive hookah smokers, ex-consumers of cigarettes having one day stopped smoking or yet having substituted for it the hookah practice. Indeed, as pointed out by several researchers in Turkey, narghile smokers, particularly those who are dependent, belong to this last category.
Let's take the case of CHINA. It is surprising to see the authors cite only one study, that of QIAO (26) and gloss over other important ones focussing on the very same region of China. LUBIN et alii, for instance, concluded with the following statement : [water] "pipe smoking may be less deleterious than cigarette smoking. The reasons for this are unclear, but may be due to the filtration action of the water bath or to less vigorous inhalation of pipe smoke".
The same applies for HAZELTON and alii's important study based on the use of a two-stage clonal expansion model (incl. nested dose-response models for the parameters) in which one can read: "Smoking a bamboo waterpipe or a Chinese long-stem pipe appears to confer less risk than cigarette use, given equivalent tobacco consumption". Indeed, HAZELTON found that "the arsenic-tobacco interaction also appears to be very important", a crucial point that previous studies, as the above-mentioned by LUBIN, for instance, did not take into due consideration.
As for the INFECTIOUS DISEASES listed by KNISHKOWY and AMITAI, they are not clearly established. As I said in a recent publication (2004):
Other pathologies like oral, gastric cancer and of the bladder, the eczema of contact, tuberculosis or aspergillosis, etc. (El-Hakim 1999, Gunaid 1995, Bedwani 1997, Onder 2002, Munckhof 2003, Salem 1973, Shadi 1985, Szyper-Kravitz 2001) are not clearly established because of a non-rigorous methodology (simultaneous use of other products [e.g. qât, cigarettes, etc ], strongly neglected hygiene, statute and career of the not specified smokers, etc).
The case of SZYPER-KRAVITZ and alii is particularly striking because the patient he analysed did not change the water of his hookah for weeks whereas it is a common practice to do so at the end of each session, i.e., one to several times each day.
Finally, the authors strangely insist on a non-established relation: « Drugs or alcohol is often added to the tobacco ».1 It is sad because a water pipe is definitely not an efficient device for a cannabis user. Studies showed that a hookah (narghile) is very efficient to water down cannabinoids (SAVAKI 1976, LAZARATOU 1980).
I hope these comments will be helpful in the future. Thank you for your attention.
Kamal CHAOUACHI, Researcher in Tobaccology and Anthropology
Author of the first comprehensive academic publications on water pipe (hookah, shisha, narghile) smoking: a 420 page doctoral thesis (2000), 2 books (1997, 2003) and among others, recent, published and ongoing, peer-reviewed scientific reviews.
- Chaouachi K. « Shisha, hookah. Le narguilé au XXIe siècle. Bref état des connaissances scientifiques ». Le Courrier des Addictions 2004 (Oct) ; 6 (4) : 150-2.
- A four-fold review for the medical journal Tabaccologia (de la Societa Italiana di Tabaccologia):
_________OTHER REFERENCES CITED IN THIS LETTER:
Conflict of Interest:
None declared