Rapid Responses to:
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Rapid Responses: Rapid Responses published:
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Hookah Smoking: A Few Comments on Some Errors and Misconceptions
- Dr Kamal T. Chaouachi (15 August 2007)
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Breaking the bubble of the hubbly bubbly; the wider aspect
- Suzie S Ammar-Allsop, Brian G. Carpenter (9 September 2008)
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UK Ban on Smoking in General and on Hookah Smoking in Particular Should Not Stay (*)
- Dr Kamal Chaouachi (18 March 2009)
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Carcinogens and carbon monoxide in sidestream waterpipe emissions
- Alan L Shihadeh (15 April 2009)
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UK Ban on Cigarette and Hookah Smoking : Why Not Call Down the Precautionary Principle ?
- Kamal Chaouachi (20 April 2009)
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Findings on Waterpipe Second Hand Smoke
- Alan Shihadeh (20 October 2009)
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The Glamour of the Hookah
- Richard W Fawcett (22 October 2009)
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Re: Findings on Waterpipe Second Hand Smoke
- Kamal Chaouachi (11 November 2009)
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Dr Kamal T. Chaouachi, Researcher and Consultant in Tobacco Control Paris Universities (France)
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Dear Editor, Although I will be critical of its content, I
first wish to thank the authors of the paper on hookah smoking [1]
because they did not use the neo-word “waterpipe” which has caused, as you may
know, a global confusion over the past years. They have used the common term in
the English-speaking world, namely hookah, and this is perfect. However, the
publication was actually an “invited analysis” for your journal and supposed to
comply with the aims of the latter, clearly defined as follows: “The aims of
the BMJ are to publish rigorous accessible information that will help doctors
improve their practice and will influence the international debate on health.”
I am afraid these objectives were not entirely reached and I hope my comments
will help its authors to improve their work. As a researcher in anthropology
and tobaccology (or, in other words, and to make it shorter for
English-speaking readers, a medical anthropologist) specialising in this very
topic (shisha, hookah, narghile smoking) for more than 10 years now [2],
I thought it was my duty not to leave uncommented some errors and
misconceptions that I will highlight below. Indeed, such a situation may
contribute to a growing global confusion that now reached the World Health
Organisation [3]. ERRORS and MISCONCEPTIONSØ “CHOKE”. “Some hookahs have a ‘choke’ which
can be manipulated to control the amount of smoke inhaled.” This “choke” is in fact a valve the
purpose of which is to empty (partially or totally) the water vessel from smoke
when it happens that there is an over-production of the latter. As for the
control of the amount of inhaled smoke itself, it is performed by the smoker by
filling her/his lungs to the desired volume. This is how smokers have smoked
for ages. Ø ELECTRIC HOOKAH. “An interesting recent development
is the introduction of the ‘plug and inhale’ electric burners, which offer a
much quicker smoke than the original charcoal burners”. The electric burners do not
provide with a quicker smoke and need considerable improvement. Indeed, their
main “technical problem” is that they either over-burn the tobamel (the tobacco
[or no-tobacco]-molasses based smoking product) or are very slow at reaching
the right temperature for the distillation process to take place. They are
based on an electric resistance and, because of the known phenomenon of
electronic “inertia”, they cannot instantaneously (depending on the inhalation
stimuli) reach a given temperature and easily keep it steady. A broad
comparison could be made with a flatiron or a bread-toaster. Ø 100 MILLION USERS. “There are now an estimated 100
million daily users of the hookah worldwide.” Gatrad et al wrongly credit a study (Ward KD
et al.) for this figure. More, the source of this figure was never revealed by
any researcher in the world. Instead, with many other “facts” in relation to
hookah smoking, the accuracy and the sources were never verified all the more
that the Internet has been an illusion for many people. Ø EGYPT. “In Egypt, for example, younger adults
prefer fruit flavoured – apple, mango and mixed fruit – tobacco, whereas older
people tend to prefer molasses (Figure 4). Molasses are thick treacle like
syrups made as a by-product of sugar cane; these have the advantages of burning
just as tobacco leaf products does, but being nicotine free”. This statement is completely wrong. “Older people” in Egypt do NOT “tend
to prefer” to smoke “nicotine-free” “molasses”. For more details, I am ready to
provide with many references of the relevant anthropological literature. Ø DRUGS. “Whilst the hookah is commonly used
for smoking herbal fruits after meals, of concern is that it has in recent
years increasingly been used for smoking tobacco, massel (aromatic tobacco),
cannabis and bango (an intoxicating plant leaf)”. This statement is
also wrong and unsupported. Hookahs have been around for centuries and were
used, not to smoke “herbal fruits”, but pure tobacco and tobacco-molasses based
products. The remote origins of hookahs are also linked to the use of drugs so
this is not a recent trend. Therefore, the only new recent evolution is the
rather heavy use of flavouring essences [2]. Ø CHILDREN AND FATHERS. “The hookah is commonly shared
amongst family members including children, friends and guests”. It is again wrong and contrary to
all available anthropological observations to say that children smoke the
hookah with their fathers [4]. Ø NICOTINE. “Nicotine content in hookah tobacco
appears to be no different from
cigarettes”.
On the contrary, it is very different and extremely variable at the same time.
A recent independent and sound study has established these differences [5]. Ø CARBON MONOXIDE. “This is particularly so [carbon
monoxide poisoning] with smaller hookah pipes and ‘quick lighting’ commercial
charcoal”. Apart
from an error concerning the “quick lighting” charcoal, Gatrad et al. credit a
dubious internet resource for this statement. We think that citing a secondary
-not to say tertiary- bibliographical source- is definitely not the sounder way
to move research forward in this field. As for the bigger the hookah the
less carbon monoxide it produces, the right source is Sajid et al. [6].
Besides, we were the first to advertise the findings of this highly original
Pakistani team in a meeting of the French Society of Tobaccology nine
years ago [7] Ø “ARAB AMERICAN ADOLESCENTS”. The corresponding cited
study by Rice et al. [8] was based on highly questionable questionnaires. We do not understand
why Gatrad et al. did not also mention a remedy to this problem: a promising
approach designed by a team in the United Kingdom [9]. Ø DISEASES. As for other diseases (chromosome
damage, etc.), we cannot but draw the attention of researchers on the growing
confusion caused by repeating again and again the related findings. Critical
attention is the key word to move research forward in this field. This is what
I recently said to Dr Urkin [10]. Ø GATEWAY TO DRUG TAKING. “There is also a need for
greater understanding about how, when and why it is used, and the risks of
progressing from use of aromatic fruits to tobacco to illegal products”. I
am surprised not to see the authors first express their concern over the role
of the widely spread cigarettes. Indeed, is not it commonplace for many
adolescents of the world to roll up a (cannabis) “joint” by removing the tobacco
rod of a Marlboro cigarette freely purchased from the not less widespread
tobacco outlets ? CONCLUSIONFrom my disciplinary scientific perspective -at
the crossroad of Health, Anthropology and Continents-, I cannot accept the idea
of basing an analysis on “the role of hookahs in Arab society” on “a
number of helpful discussions” with “Dr Yasser Shehata” or anybody else. The
same for supposed “observations of children in hookah parlours” based on
talks with another individual (Irshad Ibrahim). What we need is scientific
observations and studies on the real world of real hookah smokers. Hundreds of
pages have been published on the subject and are quite comprehensive [2].
Should others need to be carried on, this can be done quite easily and quickly. Let me repeat once again that the key to the
complex issue of shisha (hookah, narghile) smoking is anthropology,
particularly medical anthropology. Short-circuiting this approach, as this has
been done continuously since 2001, and refusing to take into account the
existing relevant studies, is definitely not the right method. Many errors
could have been avoided through the necessary transdisciplinary, transnational
and transcultural collaboration for a global public health problem [4]. Sadly
enough, this did not happen so far and the best method to make hookah smoking
more and more popular in the world is to disseminate highly questionable papers
and publications on the subject and let the mass media blindly echo them. Dr Kamal T.
Chaouachi Researcher and Consultant
in Tobacco Control (Paris) Contact: kamchaAgmail.com __________ References[1] Gatrad R, Gatrad A, Sheikh
A. Hookah
smoking. BMJ 2007 Jul
7;335(7609):20. [2] Chaouachi K. The Medical Consequences of Narghile (Hookah,
Shisha) Use in the World. Revue d’Epidemiologie et de Sante Publique (Epidemiology and Public
Health) 2007;55(3):165-70. [Article in English] http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=AbstractPlus&list_uids=17446024&itool=pubmed_DocSum
[3] Oxman AD, Lavis
JN, Fretheim A. Use of evidence in WHO recommendations. The Lancet Early
Online Publication 2007 (9 May). DOI:10.1016/S0140-6736(07)60675-8 http://www.thelancet.com/journals/lancet/article/PIIS0140673607606758/fulltext [4] 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 [5] 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; 11: 449-55 [6] Sajid Km, Akther M, Malik GQ. Carbon
monoxide fractions in cigarette and hookah. J
Pak Med Assoc 1993 (Sep); 43(9):179-82. [7] Communication (« Le narguilé »).
XIIIème Journée de Tabacologie. Centre Hospitalier de Villejuif. 10 octobre 1998. [8] Rice VH, Weglicki LS, Templin T, Hammad A,
Jamil H, Kulwicki A. Predictors of Arab
American adolescent tobacco use. Merrill-Palmer
Quarterly 2006;52: 327-42. [9] Hanna L, Hunt S, Bhopal RS. Cross-cultural adaptation of a tobacco questionnaire
for Punjabi,Cantonese, Urdu and Sylheti speakers: qualitative research for
better clinical practice, cessation services and research .
Journal of Epidemiology and Community Health 2006;60:1034-1039. Comments
(18 Jan. 2007): http://jech.bmj.com/cgi/eletters/60/12/1034#1288
[10] Urkin J., Ochaion
R, Peleg, A. Hubble Bubble Equals Trouble: The hazards of water pipe smoking.
TSW Holistic Health & Medicine 2006; 1:34-41. Comments
(18 June 2007): Competing interests: None declared |
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Suzie S Ammar-Allsop, Pharmacy Graduate School of Pharmacy and Biomedical Sciences, University of Portsmouth PO1 2DT, Brian G. Carpenter
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Although the Analysis by Gatrad and colleagues has demonstrated the problems waterpipe smoking (Hookah, Shisha, Narghile) presents for children from the Middle East and Asia there has to be concomitant concern about the attitudes within the whole of Western Society to this type of smoking. The last few years have shown a considerable increase in the use of waterpipe smoking throughout Europe and North America. This applies particularly to young people and students and not just those from traditionally associated ethnic groups [1]. The dangers associated with waterpipe smoking does not appear to be appreciated by most participants and in this respect the media,inadvertently, has not helped. Suggestions and comments made recently in the U K have included minimal health risk because non-tobacco products can be smoked, and the water filled bowl can efficiently filter out noxious products present in the smoke aerosol. As part of the social scene, the hookah has been presented as an object of modernity in both chic commercial establishments and open air restaurants. A survey of the literature shows that research into water pipe smoking has mainly focused on respiratory and cardiovascular effects while analytical work from the American University of Beirut [2] has revealed some of the toxic compounds in the aerosol emanating from popular flavoured tobaccos. We have recently generated data pertinent to the efficiency of the water to remove potentially hazardous compounds. Some of these are removed by the water,the nature and relative amounts varying when the pH is changed from 7 to 3.5, but large quantities still pass through to the mouth piece. Smoking non-tobacco products can eliminate nicotine, but it is not likely to reduce the accompanying carbon monoxide and there is a strong possibility that toxic compounds, similar to those identified by the Beirut group [2], will be produced during combustion. The original non-smoking legislation put forward in Vancouver, Canada in 2007 had actually exempted the indoor use of hookah pipes (under specified conditions) [3] thereby allowing the public to believe they were less harmful than cigarette smoking. However the Health Protection Director for the City has recently recommended that the Council revoke this exemption and bring hookah lounges in line with the new by-law. For the reasons indicated we believe it is essential the general public should be made much more aware of the hazards of water pipe smoking and that much more effort be put into the research of this activity. 1.An emerging deadly trend: waterpipe tobacco use. American lung Assoc.Feb 2007. Available from: http://www.lungusa.org 2. Shihadeh A, Saleh R. Polycyclic aromatic hydrocarbons, carbon monoxide, tar and nicotine in the mainstream smoke aerosol of the narghile water pipe. Food and Chemical Toxicology 2005: 43: 655-661 3. Heinman C. Sales of hookah pipes and tobacco are surging. Times Colonist (Canada), 2007-08-21. Competing interests: None declared |
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Dr Kamal Chaouachi, Tobacco Researcher and Consultant Paris (France)
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In my previous comment on
Gatrad et al.’s paper, I had identified a certain number of errors [1][2].
However, I realised only recently that the context of their paper was not so
innocent and that one of its objectives was to justify, on scientific grounds,
the United Kingdom (UK) ban on hookah smoking. The following statement, below a
heading entitled "Implications of UK Health Act”, is quite clear in this respect: “When used for smoking tobacco, the hookah is included in the
legislation that came into force in England in July 2007 banning smoking in
public places. We believe that including the hookah in the legislation is
appropriate since the exposure of non-smokers to tobacco fumes is
considerably higher than for cigarette smoking because of the large plume of
smoke that the hookah generates. […]”[1] What Gatrad and his
colleagues did not realise is that the “large plume of smoke” is actually and
exclusively exhaled mainstream smoke, i.e. aged, water-filtered and
respiratory-tract filtered smoke, not side-stream smoke (as with cigarettes).
The chemical differences and public health consequences are so immense and this
has been established for the first time in a recently published study [3].
Even hookah mainstream smoke,
the one to be found inside the device and before it enters the lungs of the
hookah user through the long suction hose, is much less complex (a few hundreds
of chemical compounds) than its cigarette equivalent (ca. 4700 chemicals).
Furthermore and notably, it is mainly made up of water and glycerol which are
both biologically inactive. In France, and in spite of a ban similar to the UK
one, hookah lounges stayed open because the above arguments were paid due
attention to by the Ministry of Health. Unfortunately, this did not happen in
the UK [3]. Basically, the new study shows that the WHO (World Health
Organisation) report was wrong, among other errors, to state that “second-hand
smoke from waterpipes […] poses a serious risk for non-smokers” [4][5]. Concerning smoking in general
(i.e. mainly cigarette smoking), it appeared that the epidemiologic
sources on which some corresponding European laws relied, were either
manipulated or unscientific [6]. Enstrom and Kabat have carried out a
study published in BMJ whose conclusions do not apparently support any similar
law in the USA or elsewhere [7][8]. In these conditions, it is
amazing to hear of ETS (Environmental Tobacco Smoke) hazards caused by a device
known to produce NO side-stream smoke,
unlike cigarettes, as early noticed by an “observant” team [9]. Conclusion. Based on the
above-mentioned research on ETS (cigarettes in general and hookah in
particular), the conclusion is that the UK Ban on smoking should be lifted as
soon as possible. For the scientific credibility of public health interventions
among the public, it is important to stress that tobacco use is dangerous and
particularly tobacco smoking. However, active smoking completely differs from
passive smoking [3]. Dr Kamal Chaouachi PS: One of the references
cited by Ammar-Allsop and Carpent in their Rapid Response to Gatrad et al.’s
article is that of a report prepared by the American Lung Association [10][11].
Its cover shows a small sized hookah generating side-stream smoke on its own.
As early said, this is nonsense and this has been pointed out in our study [3].
Furthermore, readers familiar to what a hookah and a hookah smoker are, will
notice that the “smoke” is that of a cigarette, not that generated by a hookah. _______ References: [*] Ban On Hookah Smoking Should Stay, Argue Doctors,
England. Medical News Today 2007 (6 Jul) http://www.medicalnewstoday.com/articles/76015.php [1] Chaouachi K. [Rapid
Response ] Hookah Smoking: A Few Comments on Some Errors and Misconceptions.
British Medical Journal 2007 (15 Aug). http://www.bmj.com/cgi/eletters/335/7609/20#174592 [2] Gatrad R, Gatrad A, Sheikh A.
Hookah smoking. BMJ 2007 Jul 7;335(7609):20. [3] Chaouachi K. Hookah (Shisha, Narghile) Smoking
and Environmental Tobacco Smoke (ETS). A Critical Review of the Relevant
Literature and the Public Health Consequences. International Journal of
Environmental Research and Public Health. 2009; 6(2):798-843. http://www.mdpi.com/1660-4601/6/2/798/ [4] World Health Organisation/TobReg. Waterpipe
Tobacco Smoking: Health Effects, Research Needs and Recommended Actions by
Regulators. Advisory Note, 2005. [5] Chaouachi K. A Critique of the WHO’s TobReg “Advisory Note” entitled: “Waterpipe Tobacco
Smoking: Health Effects, Research Needs and Recommended Actions by Regulators”
(2005). Journal of Negative Results in Biomedicine 2006 (17 Nov); 5:17. http://www.jnrbm.com/content/pdf/1477-5751-5-17.pdf
[6] Molimard R. [The European Report "Lifting the
SmokeScreen": Epidemiological study or manipulation?] Rev
Epidemiol Sante Publique. 2008
Aug;56(4):286-90 [English Abstract; article in French]. http://www.formindep.org/L-article-integral-du-professeur
[English full text version] [7]
Enstrom JE, Kabat GC. Environmental tobacco smoke and
tobacco related mortality in a prospective study of Californians, 1960-98 BMJ
2003; 326: 1057 [8] Enstrom JE. Defending legitimate epidemiologic
research: combating Lysenko pseudoscience. Epidemiologic Perspectives &
Innovations 2007 (10 Oct);4:11 http://www.epi-perspectives.com/content/4/1/11 [9] Deckers SK, Farley J, Heath J. Tobacco and its
trendy alternatives: implications for pediatric nurses. Crit Care Nurs Clin
North Am 2006 (Mar);18(1):95-104. [10] Ammar-Allsop SS, Carpenter BG. Breaking the bubble of the hubbly
bubbly; the wider aspect. BMJ 2008 (9 Sep). http://www.bmj.com/cgi/eletters/335/7609/20#201685 [11] ALA (American Lung Association). An Emerging Deadly Trend:
Waterpipe Tobacco Use. 2007 (Feb). http://slati.lungusa.org/alerts/Trend%20Alert_Waterpipes.pdf Competing interests: « I have unfortunately never received direct or indirect
funding [$] neither from pharmaceutical companies (nicotine
"replacement" therapies and products) nor from the tobacco industry. If I had, I would certainly have earned a better living. I was
the first to publish results of (ambient and alveolar) Carbon Monoxide levels
in hookah lounges and their patrons (Tobaccology thesis 1998; Alcoologie 1999;
Doctoral thesis 2000) and subsequently issued public health recommendations in
this respect. Out of this concern, I have participated by year 2004 in the
design of a harm reduction hookah (cutting down CO by 95%) of which I am an
official co- inventor (Patent 2005. "Narguile a allumage simplifie"
[Narghile with simplified ignition]. Appl. EP20050291196. Filed 3 June.
Published 14 Dec). My participation in the project was frozen by Autumn 2004.
However, the official termination was formalised only by 15 June 2005, date by
which I have signed away and ceded all my rights regarding the invention
(legally certified by State Attorney in Paris). I began to publish hookah
studies in peer-reviewed biomedical journals only beyond that date. For more details, go to: http://www.harmreductionjournal.com/content/5/1/19/comments#304579 (Section 13) More evidence on the total absence of conflict of interest in relation
to my research on the issue can be found in the PubMed database itself: http://www.ncbi.nlm.nih.gov/sites/entrez (enter “chaouachi k”). [$] On this notion of “indirect funding”, see: Rose JE. Ethics of tobacco company funding. Science. 2005 Apr 29;308(5722):632. |
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Alan L Shihadeh, Professor American University of Beirut , Beirut, Lebanon 1107-2020
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We are currently in the final year of a 3 year study on second-hand narghile (shisha, hookah) waterpipe smoke sponsored by the RITC. To date, we have measured large quantities of volatile aldehydes, carcinogenic polyaromatic hydrocarbons, and carbon monoxide *issuing directly from the waterpipe head* into the immediate environment. While there is no continuously visible plume of smoke rising from the head while it is being smoked, there are nonetheless large quantities (e.g. an order of magnitude greater than what is emitted by a single cigarette) of harmful substances emitted directly into the environment. Banning waterpipes from public places is at least as justifiable as banning cigarettes. Competing interests: None declared |
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Kamal Chaouachi, Tobacco Researcher and consultant Paris
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Thanks for the news. Shihadeh
says about hookah (shisha, narghile) passive smoking [Second-Hand Smoke;
Environmental Tobacco Smoke (ETS)][1] more or less what he has found in
his previous studies about active smoking. The latter relates to hookah
mainstream smoke [MSS], i.e. the one that goes directly into the
smoker’s mouth. In a few words, hookah MSS would be much more hazardous to
health than cigarette smoke. This has led respectable antismoking organisations
such as ASH (Action on Smoking and Health) to public declare -ahead of the UK
Ban on smoking in public hospitalities (July 2007)- that “[hookah is] “200
times worse than a cigarette” say Middle East experts”” [2]. Shihadeh acknowledges that “there
is no continuously visible plume of smoke rising from the waterpipe head while
it is being smoked”. Therefore, either the UK experts who supported the
nationwide ban (Gatrad et al, among others)[3] had a flawed vision or
public posters and pictures (French INPES, United States ALA) have been
manipulated by antismoking organisations [4]. In these conditions, the
first revelation is that there would be a sort of invisible Side-Stream Smoke
(SSS) containing large quantities of highly toxic substances (volatile
aldehydes, PAHs, CO) directly generated by the bowl [1]. I only hope
that such a revelation will not consist in inferring that the chemical analysis
of the actual black smoke emitted by the commercial (non-natural, quick
lighting) charcoal during the first two or three minutes of its ignition [5],
is valid for the rest of the one hour (or more) long smoking session. I also hope that the researchers,
contrary to what they have done in previous studies of theirs, will compare the
potential SSS emissions, on one hand, in a hookah in which the charcoal is thermally
separated (aluminium foil or metal screen) from the smoking mixture
(tobamel/moassel) and, on the other, in a (traditional) pipe in which it is in
direct contact (tumbak, jurak). For those who do not know what a
hookah is and how its (modern) users smoke it, it is necessary to emphasise
here that the commercial quick lighting charcoal is lit outdoors and not
indoors (home, hookah lounge, etc.) just as Asian and African people have been
doing with natural charcoal for centuries. Public health recommendations
directly related to this aspect were issued more than 10 years ago, i.e. long
before the emergence of fashionable hookah lounges [5]. They were
sufficient and likely the best public health message together with that of
avoiding smoking hookahs in ill-ventilated places. A comprehensive critical
review on this issue concludes that, amazingly, such a simple harm reduction
prevention message was dismissed and aggressive public health plans were
favoured as against cigarette ETS in general [6]. The same key
publication concludes : “All these facts and others lead to the conclusion that hookah ETS
(not MSS) hazards will remain unwarranted until a study shows that minute
amounts of toxicants present in hookah EMSS may cause serious diseases as
some researchers state about cigarette ETS [7].
Most recently, an interesting study showed that, given that there would be no
safe level of exposure to tobacco smoke, ThirdHand Smoke (defined as
residual tobacco smoke contamination that remains after the cigarette is extinguished)
may be extremely hazardous, particularly for children at home [8].
It is also noted that in the case of cigarette smoking, where, unlike
hookah, SSS is generated, exposed non-smokers do not breathe deeply,
particularly when they are exposed to tobacco smoke […]”[6]. The other revelation is that 2009
would be the “final year of [this] 3 year study” on hookah ETS. On one hand, it
is certainly a quite long time frame. On the other, this means that this study
was launched long after the release of the WHO flawed report on ““waterpipe””
smoking -which states, among a long series of serious errors : “Second-hand
smoke from waterpipes […] poses a serious risk for non-smokers”[9][10]. The WHO statement was therefore
issued 4 years before the results, revealed only yesterday in the BMJ in the
form of a Rapid Response, that non-smokers, over several centuries of the
hookah tradition, would have to stand the great hazards of its ETS… It sounds
as convincing as the question of cigarette Third Hand Smoke [8]. Perhaps
there is also a serious risk for Hookah Third Hand Smoke… We will wait until
these results are published in a scientific journal. We will be ready to
discuss them if the debate is not obstructed as it unfortunately and generally
is when it comes to these burning issues. Shihadeh insists that “Banning
waterpipes from public places is at least as justifiable as banning cigarettes”.
May I ask : “justifiable” for whom ? In a previous move, the same expert did
not put forward ETS as a key argument but another one. He warned, together with
two antismoking colleagues, that “excluding “shisha bars” when England goes
smokefree on July 1 [2007] could worsen the grave inequalities in health
that already affect ethnic minorities” [2]. In fact, such a ban,
based on absent or poor science, meant the economic death of “ethnic
minorities” commercial activities, the loss of their health insurance and of
their families too and other unexpected social problems”. Tobacco (particularly
when smoked) is dangerous for health and may be very dangerous in certain
occasions. However, passive smoking is completely different from active smoking
[6]. UK Ban on
cigarette and hookah smoking in public hospitalities should not stay. Otherwise
and against the background of a world confusion, let public authorities clearly
call down and officially mention the precautionary principle. Dr Kamal
Chaouachi PS: The 3 year study is said to be
funded –beside the US-American University of Beirut itself, I presume-, by the
North American RITC (Research on International Tobacco Control; Canada)[11].
It should noted, however, that among the advertised “Strategic Partners” of the latter, the names of
two multinational pharmaceutical companies appear after a list of world
antismoking organisations: namely, Glaxo-Wellcome/Smith Kline Beecham and
Merrck-Frost. __________ References: [1]
Shihadeh A. Carcinogens and carbon monoxide in sidestream waterpipe emissions. BMJ 2009 (15 Apr) http://bmj.com/cgi/eletters/335/7609/20#212232 [2]
ASH (Action on Smoking and Health). ““Shisha 200 times worse than a cigarette”
say Middle East experts””. 27 March 2007 (prepared by Martin Dockrell)(accessed
13 June, 2008). [based, among others, on an interview with Wasim Maziak and
Alan Shihadeh] http://www.newash.org.uk/ash_4q8eg0ft.htm
[3] Gatrad R, Gatrad A, Sheikh A. Hookah smoking. BMJ 2007 Jul 7;335(7609):20. [4] Chaouachi K. Is Medical Concern about Hookah Environmental Tobacco Smoke
Hazards Warranted ? [A Tribute to Gian Turci, who has recently passed away] The
Open General & Internal Medicine Journal 2009; 3:31-3. http://www.bentham-open.org/pages/content.php?TOGMJ/2009/00000003/00000001/31TOGMJ.SGM [5] Chaouachi K. The
Medical Consequences of Narghile (Hookah, Shisha) Use in the World. Revue
d’Epidemiologie et de Sante Publique (Epidemiology and Public Health)
2007;55(3):165-70 [in English]. [6] Chaouachi K. Hookah
(Shisha, Narghile) Smoking and Environmental Tobacco Smoke (ETS). A Critical
Review of the Relevant Literature and the Public Health Consequences.
International Journal of Environmental Research and Public Health. 2009;
6(2):798-843. http://www.mdpi.com/1660-4601/6/2/798/ [7] Pechacek TF,
Babb S. How acute and reversible are the cardiovascular risks of secondhand
smoke? BMJ. 2004 Apr 24;328(7446):980-3. [8] Winickoff JP, Friebely J, Tanski SE, Sherrod C, Matt GE, Hovell MF,
McMillen RC. Beliefs About the Health Effects of "Thirdhand" Smoke
and Home Smoking bans. Pediatrics 2009;123;e74-e79 http://pediatrics.aappublications.org/cgi/content/abstract/123/1/e74 [9]
Chaouachi K. A Critique of the WHO’s TobReg
“Advisory Note” entitled: “Waterpipe Tobacco Smoking: Health Effects,
Research Needs and Recommended Actions by Regulators” (2005). Journal of
Negative Results in Biomedicine 2006 (17 Nov); 5:17. http://www.jnrbm.com/content/pdf/1477-5751-5-17.pdf [10]
World Health Organisation/TobReg. Waterpipe Tobacco Smoking: Health Effects,
Research Needs and Recommended Actions by Regulators. Advisory Note, 2005. [11] RITC (Research
on International Tobacco Control) http://www.idrc.ca/uploads/user-S/10905197851Program_Framework_for_RITC.htm ____________ Note
about ““waterpipe”” (one word, singular). The
use of such a scientific, reductionist and functionalist nominalism has had
calamitous consequences on hookah (shisha, narghile) research for over half a
decade now. See for instance: [*]
Chaouachi K. Micronuclei and Shisha/Goza Smoking in Egypt. Mutation
Research/Genetic Toxicology and Environmental Mutagenesis 675 (2009) 81–82. http://dx.doi.org/10.1016/j.mrgentox.2008.11.017 Competing interests: About
my unfortunately non-existent
financial and non-financial competing interests, please refer to the relevant
parts of the following open access sources: [1] Chaouachi K. [E-Letter] UK Ban on Smoking in
General and on Hookah Smoking in Particular Should Not Stay. British
Medical Journal2009 (18 Mar): http://bmj.com/cgi/eletters/335/7609/20#210647 [2]
Chaouachi K. [Comment] Rebuttal (KC) to
Dr Maziak’s (26 June) Remaining Objections. Harm Reduction Journal 2008 (3 Jul) http://www.harmreductionjournal.com/content/5/1/19/comments#304579 (Section 13) [3] The PLoS Medicine Editors. Making Sense of Non-Financial Competing
Interests. PLoS Medicine 2008 (30 Sep); 5(9): e199. http://medicine.plosjournals.org/perlserv/?request=get-document&doi=10.1371/journal.pmed.0050199 [4] Enstrom J. [Reader’s Response] Using the Internet to Disclose Competing
Interests. PLoS Medicine 2008 (03 Nov). |
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Alan Shihadeh, Associate Professor American University of Beirut, Beirut, Lebanon 1107-2020
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Our group recently published data on measured waterpipe (narghile) sidestream smoke emissions. The data show clearly that there is strong justification for including waterpipes in public smoking bans. We found that during a typical one-hour use session, one waterpipe smoker likely generates as much carbon monoxide and airborne lung carcinogens as 2-10 cigarette smokers over the same period. See doi:10.1016/j.atmosenv.2009.10.004 Competing interests: None declared |
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Richard W Fawcett, Senior House Officer and Anatomy Demonstrator School of Medicine, University of Birmingham, B152TT
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The intricacies of smoking the hookah mean that it is not only a bad habit, as with smoking cigarettes, but a social occasion, lacking the taboo widely accepted with smoking other forms of tobacco. Firstly, the apparatus is a near work of art, designed to add glamour. While to merely set up a hookah requires formidable knowledge, adding to respect its use may have among the young. The use of flavoured tobacco is a huge factor in its popularity. The lack of the initial bad taste of smoking tobacco is simply not there, meaning, as the authors correctly state, that children and women are far more easily drawn to its use. A serious issue is the existence of 'hookah bars', places designed entirely around smoking different types and flavours of the tobacco. One would have thought that the introduction of the smoking ban may have prevented being able to make a business out of this, however, the use of cosy, outdoor, sheltered areas with outdoor heaters is a clever way to overcome the issue. Despite the details of the harmful effects not being fully understood, the fact is that the logistics of hookah use mean that in order to use the apparatus correctly a near full inspiratory effort is required. Add to this the fact that smoking the hookah is deemed a social activity in its own right, most users are likely to spend the majority of the evening with lungs full of tobacco. Competing interests: None declared |
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Kamal Chaouachi, Tobacco researcher and consultant Paris and Middle East
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The publication by Daher et al. is an experimental study, not a human
one [1]. It is based on a ““waterpipe”” smoking machine that has been
criticised (including its smoking topography) in peer-reviewed journals [2].
Daher et al’s
paper contains serious biases. The major one is that the
measurements of toxic substances began only one minute after the quick-lighting charcoal (non-natural and the
worst in the market) was completely lit. Studies have shown that this
special coal needs several minutes before being fully ignited. During the same
period, it is well known that, among other specificities, the coal still emits
particles of a greater size than during the rest of the smoking session. Another bias is the size (67 cm height; 24 cm
diameter) of the tunnel designed to collect the side-stream smoke. The hookah
was of a small-size (also known to generate more CO than a medium or tall one).
Apparently, the same tunnel was used for the cigarette tested for comparison.
However, the length of a cigarette is about 10 cm. This means that if the
hookah was about 50 cm high, the dimensions of the tunnel were disproportionate
(5/1 ratio). There are other serious concerns about the
unrealistic dilution ageing and dilution processes and the fact that the
ventilation holes of the cigarette used for comparison were not blocked. The pipe is never smoked during the 5 first
minutes but after, so that the following statement is simply wrong: "It
can be seen that even during the first 5 minutes, the total particle
concentration in the chamber is greater for the waterpipe than for the
cigarette case (i.e. even if the waterpipe were to be smoked for only 5
minutes, it would emit a larger number of particles into the environment than a
cigarette)" [1]. Equating (with not a single linguistic
precaution) an artificial “water pipe smoking session” in a laboratory (with
all the biases this method entails)[2], with the actual intake by
smokers in a natural environment, is also unacceptable: "a single
waterpipe smoking session emits in the SS approximately 4 times the PAH and
aldehydes, 5 times the ultrafine particles, and about 35 times the carbon
monoxide emitted in the SS of a single cigarette" [1]. __________ References: [1] Daher N, Saleh R, Jaroudia E, Sheheitlia H, Badra
T, Sepetdjian E, Al-Rashidi M, Saliba N, Shihadeh A. Comparison of carcinogen,
carbon monoxide, and ultrafine particle emissions from narghile waterpipe and
cigarette smoking: Sidestream smoke measurements and assessment of second-hand
smoke emission factors. Atmospheric Environment 2009 (9 Oct) [provisional version (pdf), lacking several figures,
accessed 23 oct 2009]. http://dx.doi.org/10.1016/j.atmosenv.2009.10.004
[2] Chaouachi K. Public health intervention for narghile (hookah,
shisha) use requires a radical critique of the related “standardised” smoking
machine. Journal of Public Health
[Springer Berlin/Heidelberg] 2009; 17(5): 355-xxx. http://www.springerlink.com/content/58352477706011t0/ Competing interests: None declared |
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