Perceptions of hookah smoking harmfulness: predictors and characteristics among current hookah users

doi:10.1186/1617-9625-5-16

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Hookah Smoking Harmfulness: Correcting a Few Errors and Clarifying Some Points of Interest
Hookah Smoking Harmfulness : Correcting a Few Errors and Clarifying Some Points of Interest
Response to Comments by Dr. Kamal Chaouachi

Hookah Smoking Harmfulness: Correcting a Few Errors and Clarifying Some Points of Interest

Kamal Chaouachi (16 February 2010) DIU Tabacologie, Université Paris XI (France)

Dear Editor,

NICOTINE. Aljarrah et al state that “scientific facts indicate that “when compared to cigarette smoking […]”, "hookah smoke also contains 36 times the amount of nicotine” [1]. The authors cite for this purpose two papers from the US-American University of Beirut. In fact, this elevated figure is not that that for nicotine and it should be divided by at least 18. Indeed, there is a growing consensus among tobacco control researchers that one hookah session would not deliver more nicotine than one single cigarette.

TEMPERATURES. There is also another error concerning the working temperatures. 900°C is a common figure for the temperature at the tip of a cigarette, not inside the hookah bowl as Aljarrah et al state. 450°C is the temperature of the glowing charcoal (of the quick self-lighting type). It should be noted that there is a thermal foil screen separating the heating source from the mixture so the temperature inside the bowl hardly goes in excess of 200°C. Furthermore, tobacco (or, more properly, the tobacco-molasses based mixture) does not burn in a hookah bowl but is simply heated. These points were clarified in a commentary about the WHO report cited by the authors [2].

ORIGINS. The WHO report mentions the 16th century and not the previous one put forward by Aljarrah et al. In any case, the same above-mentioned commentary suggested, among others, a chief archeological reference showing that water pipes were dug out in Eastern Africa two centuries before [3].

GENDER USE. Aljarrah et al state that “late in the 19th century, hookah use started spreading among women in the Middle East". However, the use by women is as old as the invention of the device. A prestigious Syrian female lung specialist who has been studying this practice for two decades, clearly shows that women in this region “have been smoking narguileh water pipes for centuries” [4].

SECOND-HAND SMOKE. This problem should not be exaggerated and the focus should remain on the hazards of active hookah smoke, i.e. the one inhaled by the smoker. Indeed, US researchers have early pointed out that “one of the only articulated benefits to this tobacco alternative is the minimal release of side-stream smoke, which would ultimately place by-standers at risk for ETS exposure” [5].

GATEWAY HYPOTHESIS. This hypothesis (switching from hookah to cigarette use) is acceptable. However, one should not omit to mention negative results such as those from an important recent Australian survey involving a large sample. Its authors conclude that they “are not alarmed about potential switching as only one ex-CCP [Cigarette/Cigar/Pipe] smoker (out of 1,102 respondents) also reported smoking WT [Water pipe Tobacco] on a daily basis” [6].

________________

REFERENCES

[1] Aljarrah K, Ababneh ZQ, Al-Delaimy WK. Perceptions of hookah smoking harmfulness: predictors and characteristics among current hookah users. Tob Induc Dis. 2009 Dec 18;5(1):16. [Epub ahead of print]

http://www.tobaccoinduceddiseases.com/content/5/1/16

[2] 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/pdf/1477-5751-5-17.pdf

[3] Van Der Merwe NJ: Cannabis Smoking in 13th-14th Century Ethiopia: Chemical Evidence. In World Anthropology: Cannabis and Culture. Edited by Vera Rubin: Mouton Publ. (The Hague); 1975: 77-80.

[4] 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 Chron Obstruct Pulmon Dis. 2008;3(3):405-14.

[5] 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.

[6] Carroll T, Poder N, Perusco A. Is concern about waterpipe tobacco smoking warranted? Aust N Z J Public Health. 2008 Apr;32(2):181-2.

Competing interests

no competing interests.

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Hookah Smoking Harmfulness : Correcting a Few Errors and Clarifying Some Points of Interest

Kamal Chaouachi (20 January 2010) DIU Tabacologie, Universite Paris XI (France)

Dear Editor,

NICOTINE. Aljarrah et al state that “scientific facts indicate
that” when compared to cigarette smoking "hookah smoke also contains
36 times the amount of nicotine” [1]. The authors cite for
this purpose two papers from the US-American University of Beirut. In
fact, this elevated figure is not that that for nicotine and it should
be divided by at least 18. Indeed, there is a growing consensus among
tobacco control researchers that one hookah session would not deliver
more nicotine than one single cigarette.

TEMPERATURES. There is also another error concerning the working
temperatures. 900°C is a common figure for the temperature at the tip
of a cigarette, not inside the hookah bowl as Aljarrah et al state.
450°C is the temperature of the glowing charcoal (of the quick self-lighting
type). It should be noted that there is a thermal foil screen separating
the heating source from the mixture so the temperature inside the bowl
hardly goes in excess of 200°C. Furthermore, tobacco (or, more properly,
the tobacco-molasses based mixture) does not burn in a hookah bowl but
is simply heated. These points were clarified in a commentary about
the WHO report cited by the authors [2].

ORIGINS. The WHO report mentions the 16th century and not the
previous one put forward by Aljarrah et al. In any case, the same above-mentioned
commentary suggested, among others, a chief archaeological reference
showing that water pipes were dug out in Eastern Africa two centuries
before [3].

GENDER USE. Aljarrah et al state that “late in the 19th century,
hookah use started spreading among women in the Middle East". However,
the use by women is as old as the invention of the device. A prestigious
Syrian female lung specialist who has been studying this practice for
two decades, clearly shows that women in this region “have been smoking
narguileh water pipes for centuries”[4].

SECOND-HAND SMOKE. This problem should not be exaggerated and
the focus should remain on the hazards of active hookah smoke, i.e.
the one inhaled by the smoker. Indeed, US researchers have early pointed
out that “one of the only articulated benefits to this tobacco alternative
is the minimal release of side-stream smoke, which would ultimately
place by-standers at risk for ETS exposure” [5].

GATEWAY HYPOTHESIS. This hypothesis (switching from hookah to
cigarette use) is acceptable. However, one should not omit to mention
negative results such as those from an important recent Australian survey
involving a large sample. Its authors conclude that they “are not
alarmed about potential switching as only one ex-CCP [Cigarette/Cigar/Pipe]
smoker (out of 1,102 respondents) also reported smoking WT [Water pipe
Tobacco] on a daily basis” [6].

________________

REFERENCES

[1] Aljarrah K, Ababneh ZQ, Al-Delaimy WK. Perceptions of hookah smoking harmfulness: predictors and characteristics among current hookah users. Tob Induc Dis. 2009 Dec 18;5(1):16. [Epub ahead of print]

http://www.tobaccoinduceddiseases.com/content/5/1/16

[2] 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/pdf/1477-5751-5-17.pdf

[3] Van Der Merwe NJ: Cannabis Smoking in 13th-14th Century Ethiopia: Chemical Evidence. In World Anthropology: Cannabis and Culture. Edited by Vera Rubin: Mouton Publ. (The Hague); 1975: 77-80.

[4] 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 Chron Obstruct Pulmon Dis. 2008;3(3):405-14.

[5] 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.

[6] Carroll T, Poder N, Perusco A. Is concern about waterpipe tobacco smoking warranted? Aust N Z J Public Health. 2008 Apr;32(2):181-2.

Competing interests

no competing interests.

top

Response to Comments by Dr. Kamal Chaouachi

Khaled Aljarrah (16 February 2010) Jordan University of Science and Technology

We thank Dr. Chaouachi for providing valuable comments on our article and finding two typos that we missed. The first typo was calculating and using the number 36 when it should be 3.8 in the statement “hookah smoke also contains 36 times the amount of nicotine” based on table 2 in the reference by Shihadeh 2005 [1] that we cite. The second typo is mistakenly switching 900 with 450 and 450 with 900 for the respective temperature of cigarettes and hookahs [2].
For the other points raised by Dr. Chaouachi we do have different explanations and understandings based on the published literature. Under his comment titled “NICOTINE”, we do not agree that one hookah session would not deliver more nicotine than one single cigarette [3, 4]. We also disagree with his comment titled “TEMPERATURES” that the temperature inside the bowl hardly goes in excess of 200 °C because Shihadeh’s experiment measures a 450 °C temp for the tobacco nearest to the heat source in the hookah and not 200°C [2].
His comment titled “ORIGINS “ about the origins of hookah going back to earlier years than we report, cites a reference to a book that we do not have access to and we quote official and accessible WHO documents. Furthermore, it was reported by Karen Stephenson about the history of the hookah as “hookah got their origin in the North West part of India almost one thousand years ago” but it was modernized during the Mughal Reign (1500) to be similar to what we now know and then underwent further changes afterwards [5]. Therefore, it could be in many other older forms in earlier times. For the “GENDER USE” comment; our statement says « started spreading » meaning it became more common. This does not exclude that women started smoking it prior to that, as mentioned by Dr. Chaouachi. In terms of “SECOND-HAND SMOKE”, we don’t feel we are exaggerating this problem for hookah, but we think that hookah side-stream smoke (SSE) should receive more attention. Recently a publication by Monzer B. et. al. conclude that a very high percentage of CO and high yields of PAH are produced by charcoal used for smoking hookah [6]. Moreover, we think that there should be a focus on the risk associated with the SSE from hookah per se rather than in comparison to cigarette SSE. The experiment by Maziak et al 2008 clearly demonstrated a very high particulate matter from side stream smoke of hookah that was comparable or higher than cigarettes [7]. In our observation when carrying out the study in hookah lounges the rooms were filled with smoke.

Finally, in terms of the “GATEWAY HYPOTHESIS” of people switching from hookah to cigarettes, this is a very strong and dangerous possibility given the levels of nicotine produced by one hookah session. The study cited by Dr. Chaouachi that failed to find people switching still suggest strategies to control hookah because half of the users are currently nonsmokers (i.e they can switch and become smokers).

As with any new field, hookah-related research is still under development and varying accounts and interpretations are acceptable. We therefore thank Dr. Chaouachi for his contribution and comments.

References

1. 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(5):655-661.
2. Shihadeh A: Investigation of mainstream smoke aerosol of the argileh water pipe. Food and Chemical Toxicology 2003, 41(1):143-152.
3. Macaron C, Macaron Z, Maalouf M, Macaron N, Moore A: Urinary cotinine in narguila or chicha tobacco smokers. The Lebanese medical journal 1997, 45(1):19 -20.
4. Neergaard J, Singh P, Job J, Montgomery S: Waterpipe smoking and nicotine exposure: a review of the current evidence. Nicotine & Tobacco Research 2007, 9(10):987 994.
5.BMC
6. Monzer B, Sepetdjian E, Saliba N, Shihadeh A: Charcoal emissions as a source of CO and carcinogenic PAH in mainstream narghile waterpipe smoke. Food and Chemical Toxicology 2008, 46(9):2991-2995.
7. Maziak W, Rastam S, Ibrahim I, Ward KD, Eissenberg T: Waterpipe-associated particulate matter emissions. Nicotine & Tobacco Research 2008, 10(3):519-523.

Competing interests

No competing interests.

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