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Correspondence |

More Rigor Needed in Systematic Reviews on “Waterpipe” (Hookah, Narghile, Shisha) Smoking FREE TO VIEW

Kamal Chaouachi, Doctorate
Author and Funding Information

From the DIU (Diplome Inter-Universitaire de Tabacologie) de l’Universite Paris XI (2006-2010), also known as Enseignement d’alter-tabacologie.

Correspondence to: Kamal Chaouachi, Doctorate, BP 50 133, 75562 Paris cedex 12, France; e-mail: kamcha@gmail.com


Financial/nonfinancial disclosures: The author has reported to CHEST that no potential conflicts of interest exist with any companies/organizations whose products or services may be discussed in this article.

Reproduction of this article is prohibited without written permission from the American College of Chest Physicians (http://www.chestpubs.org/site/misc/reprints.xhtml).


© 2011 American College of Chest Physicians


Chest. 2011;139(5):1250-1251. doi:10.1378/chest.10-2864
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Published online

To the Editor:

In most of the countries where studies on water-pipe tobacco smoking have been done over decades, the device (eg, narghile, hookah, shisha, goza, Chinese long-stemmed water pipe) and the smoking products (eg, tumbak, ajamy, tutun, jurak, moassel) have generally been described with rich details. However, recent antismoking research has reduced such a striking diversity to one sole object named “waterpipe” (in one word). Such a step has caused an unprecedented confusion in the literature, with researchers often taking one or several local, traditional water pipes for the modern, fashionable one that is causing concern to antismoking organizations.1,2 From there, quick comparisons between the above-mentioned studies have been made. Together with the questionable relevance of some bibliographic references, this is one of the main problems posed by recent systematic reviews, among them one by Raad et al3 in a recent issue of CHEST (April 2011) and one by Akl et al.4

Today’s fashionable shisha smoking generally involves a quantity of 15 to 20 g, not of plain tobacco (eg, tumbak or ajamy) as in Asia and Africa, but of a flavored smoking mixture named moassel. This last product contains a high proportion of molasses, some tobacco, and glycerol as a humectant. In these conditions, it is surprising that among the six studies5-10 strictly selected by Raad et al,3 five were not about moassel. As for the Kuwaiti study,5 the volunteers were very likely served a range of different products because this is quite common in today’s Middle East.11

In the Syrian study,9 the female daily smokers used tumbak (also named ajamy, which is much stronger in nicotine than moassel and smoked differently, like a cigar).9 In the Saudi Arabian study,7 the product is jurak, served in quantities of >70 g in the shisha bowl.11 In the three Turkish studies,6,8,10 the smoked product is similar to tumbak (plain dampened tobacco), but for some reason, it is commonly known there by the term “jurak.” Consequently, it appears that it is a misnomer, since jurak, all over the region (and in the Gulf countries, in particular), is a glycerol-free mixture of tobacco, molasses, spices, and minced fruits.11 Then, in the Turkish study by Aydin et al,8 it is striking that the so-called “nonsmokers” labeled as “passive smokers” had actually been exposed to intense cigarette and narghile smoke, either at home, at work, or in the same narghile cafés. Great caution is, therefore, required when interpreting the results of Turkish studies.

Unfortunately, Raad et al3 did not highlight the characteristics of utmost importance: product type, amount, and frequency of use. Consequently, authors of related reviews, particularly systematic reviews and meta-analyses, should realize that they face a diversity of nonstandardized pipes, smoking products, and quantities. Their use implies different temperatures, chemical reactions, and expected health effects.1,2,11,12 The cited meta-analysis about nicotine levels entailed the same bias,2,13 and in a similarly structured review on health outcomes (particularly cancer),4 Raad’s colleagues did not realize that Chinese water pipes, unlike the modern shisha, work with no charcoal and with a tiny amount of burning plain tobacco. The abuse of a neologism like “water pipe” is particularly responsible for such a situation.2,11

This kind of bias and others are unfortunately too frequent in the related literature. For instance, a recent field study of topographic characteristics of smokers aimed to demonstrate the relevance of a smoking machine modeling prototype.14 However, instead of involving 100% narghile-only smokers, among other methodologic biases, only 60% of the volunteer subjects belonged to this category, sometimes sitting two at a time (sharing the hose). The remaining volunteer subjects were cigarette users whose smoking behavior is known to be very different (considering the nicotine compensation effect).

e-Appendix 1 in Raad et al3 refers to “nitrosamine and hydrogen cyanide,” which to our knowledge has not been mentioned so far in the published literature. It also inexactly refers to necessary “intermittent rapid and shallow inhalations” to “keep the tobacco burning.” First, the smoking mixture is only heated, as the authors themselves have noted elsewhere. Second, for complex thermodynamic reasons, it does not cool down, even if the smoker does not draw on the hose. Finally, the World Health Organization report on water pipes certainly calls for more research.15 However, this document, which contains a misquotation and an error in the two first sentences, among other numerous and serious mistakes, proved not to be a sound example to follow.12 Note: in the Turkish language, the spelling of the main local water pipe is “nargile” (unlike “narghile” in English).

Ben Saad H. The narghile and its effects on health. Part I: the narghile, general description and properties [in French]. Rev Pneumol Clin. 2009;656:369-375. [CrossRef] [PubMed]
 
Chaouachi K, Sajid KM. A critique of recent hypotheses on oral (and lung) cancer induced by water pipe (hookah, shisha, narghile) tobacco smoking. Med Hypotheses. 2010;745:843-846. [CrossRef] [PubMed]
 
Raad D, Gaddam S, Schunemann HJ, et al. Effects of waterpipe smoking on lung function: a systematic review and meta-analysis. Chest. 2011;1394:764-774. [CrossRef] [PubMed]
 
Akl E, Gaddam S, Gunukula SK, Honeine R, Abou Jaoude P, Irani J. The effects of waterpipe tobacco smoking on health outcomes: a systematic review. Int J Epidemiol. 2010;393:834-857. [CrossRef] [PubMed]
 
Al Mutairi SS, Shihab-Eldeen AA, Mojiminiyi OA, Anwar AA. Comparative analysis of the effects of hubble-bubble (sheesha) and cigarette smoking on respiratory and metabolic parameters in hubble-bubble and cigarette smokers. Respirology. 2006;114:449-455. [CrossRef] [PubMed]
 
Kiter G, Uçan ES, Ceylan E, Kilinç O. Water-pipe smoking and pulmonary functions. Resp Med. 2000;949:891-894. [CrossRef]
 
Al-Fayez SF, Salleh M, Ardawi M, Zahran FM. Effects of sheesha and cigarette smoking on pulmonary function of Saudi males and females. Trop Geogr Med. 1988;402:155-123
 
Aydin A, Kiter G, Durak H, Ucan ES, Kaya GC, Ceylan E. Water-pipe smoking effects on pulmonary permeability using technetium-99m DTPA inhalation scintigraphy. Ann Nucl Med. 2004;184:285-289. [CrossRef] [PubMed]
 
Mohammad Y, Kakah M, Mohammad Y. Chronic respiratory effect of narguileh smoking compared with cigarette smoking in women from the East Mediterranean region. Int J Obstruct Pulmon Dis. 2008;33:405-414
 
Köseoğlu N, Aydin A, Uçan ES, et al. The effects of water-pipe, cigarette and passive smoking on mucociliary clearance [in Turkish]. Tuberk Toraks. 2006;543:222-228. [PubMed]
 
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;9912:1808-1814. [CrossRef] [PubMed]
 
Chaouachi K. A critique of the WHO TobReg’s “Advisory Note” report entitled: “Waterpipe tobacco smoking: health effects, research needs and recommended actions by regulators”. J Negat Results Biomed. 2006;5:17. [CrossRef] [PubMed]
 
Neergaard J, Singh P, Job J, Montgomery S. Waterpipe smoking and nicotine exposure: a review of the current evidence. Nicotine Tob Res. 2007;910:987-994. [CrossRef] [PubMed]
 
Katurji M, Daher N, Sheheitli H, Saleh R, Shihadeh A. Direct measurement of toxicants inhaled by water pipe users in the natural environment using a real-time in situ sampling technique. Inhal Toxicol. 2010;2213:1101-1109. [CrossRef] [PubMed]
 
WHO study group on Tobacco Product Regulation (TobReg)WHO study group on Tobacco Product Regulation (TobReg) Advisory Note. Waterpipe tobacco smoking: health effects, research needs and recommended actions by regulators. 2005; Geneva, Switzerland World Health Organization
 

Figures

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References

Ben Saad H. The narghile and its effects on health. Part I: the narghile, general description and properties [in French]. Rev Pneumol Clin. 2009;656:369-375. [CrossRef] [PubMed]
 
Chaouachi K, Sajid KM. A critique of recent hypotheses on oral (and lung) cancer induced by water pipe (hookah, shisha, narghile) tobacco smoking. Med Hypotheses. 2010;745:843-846. [CrossRef] [PubMed]
 
Raad D, Gaddam S, Schunemann HJ, et al. Effects of waterpipe smoking on lung function: a systematic review and meta-analysis. Chest. 2011;1394:764-774. [CrossRef] [PubMed]
 
Akl E, Gaddam S, Gunukula SK, Honeine R, Abou Jaoude P, Irani J. The effects of waterpipe tobacco smoking on health outcomes: a systematic review. Int J Epidemiol. 2010;393:834-857. [CrossRef] [PubMed]
 
Al Mutairi SS, Shihab-Eldeen AA, Mojiminiyi OA, Anwar AA. Comparative analysis of the effects of hubble-bubble (sheesha) and cigarette smoking on respiratory and metabolic parameters in hubble-bubble and cigarette smokers. Respirology. 2006;114:449-455. [CrossRef] [PubMed]
 
Kiter G, Uçan ES, Ceylan E, Kilinç O. Water-pipe smoking and pulmonary functions. Resp Med. 2000;949:891-894. [CrossRef]
 
Al-Fayez SF, Salleh M, Ardawi M, Zahran FM. Effects of sheesha and cigarette smoking on pulmonary function of Saudi males and females. Trop Geogr Med. 1988;402:155-123
 
Aydin A, Kiter G, Durak H, Ucan ES, Kaya GC, Ceylan E. Water-pipe smoking effects on pulmonary permeability using technetium-99m DTPA inhalation scintigraphy. Ann Nucl Med. 2004;184:285-289. [CrossRef] [PubMed]
 
Mohammad Y, Kakah M, Mohammad Y. Chronic respiratory effect of narguileh smoking compared with cigarette smoking in women from the East Mediterranean region. Int J Obstruct Pulmon Dis. 2008;33:405-414
 
Köseoğlu N, Aydin A, Uçan ES, et al. The effects of water-pipe, cigarette and passive smoking on mucociliary clearance [in Turkish]. Tuberk Toraks. 2006;543:222-228. [PubMed]
 
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;9912:1808-1814. [CrossRef] [PubMed]
 
Chaouachi K. A critique of the WHO TobReg’s “Advisory Note” report entitled: “Waterpipe tobacco smoking: health effects, research needs and recommended actions by regulators”. J Negat Results Biomed. 2006;5:17. [CrossRef] [PubMed]
 
Neergaard J, Singh P, Job J, Montgomery S. Waterpipe smoking and nicotine exposure: a review of the current evidence. Nicotine Tob Res. 2007;910:987-994. [CrossRef] [PubMed]
 
Katurji M, Daher N, Sheheitli H, Saleh R, Shihadeh A. Direct measurement of toxicants inhaled by water pipe users in the natural environment using a real-time in situ sampling technique. Inhal Toxicol. 2010;2213:1101-1109. [CrossRef] [PubMed]
 
WHO study group on Tobacco Product Regulation (TobReg)WHO study group on Tobacco Product Regulation (TobReg) Advisory Note. Waterpipe tobacco smoking: health effects, research needs and recommended actions by regulators. 2005; Geneva, Switzerland World Health Organization
 
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