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ELECTRONIC ARTICLE:
Barry Knishkowy and Yona Amitai
Water-Pipe (Narghile) Smoking: An Emerging Health Risk Behavior
Pediatrics 2005; 116: e113-e119
[Abstract][Full text][PDF]
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):
Chaouachi K. Presentazione del narghilè e del suo uso. Guida critica della letteratura scientifica sul narghilè (shisha, hookah, waterpipe). Dalle origini ai giorni nostri : necessità di un approccio interdisciplinare socio-antropologico, medico e farmacologico. Tabaccologia 2005; 1: 39-47.
[Eng. title] A critical review of scientific literature on narghile (Shisha, Hookah, Waterpipe) from its origins to date: the need for a comprehensive socio-anthropological, medical and pharmacological approach.
Chaouachi K. Narghile: aspetti chimici e farmacofisiologici. Tabaccologia 2005; 3: 27-33. [Engl. title: Biochemical and Pharmacologic Aspects of Narghile].
_________
OTHER REFERENCES CITED IN THIS LETTER:
Chaouachi Kamal. Serious Errors in this study [W Maziak, K D Ward, R A Afifi Soweid, and T Eissenberg. Tobacco smoking using a waterpipe: a re-emerging strain in a global epidemic. Tobacco Control 2004; 13: 327-333]. Tobacco Control online. 2 Dec. 2004. Available at http://tc.bmjjournals.com/cgi/eletters/13/4/327
Hazelton, W. D., Luebeck, E. G., Heidenreich, W. F. and Moolgavkar, S. H. Analysis of a Historical Cohort of Chinese Tin Miners with Arsenic, Radon, Cigarette Smoke, and Pipe Smoke Exposures Using the Biologically Based Two-Stage Clonal Expansion Model. Radiat. Res. 2001, 156: 78-94.
Lazaratou H, Moschovakis A, Armaganidis A, Kapsambelis V, Kiburis J, Kephalas TA. The pharmacological effect of fractions obtained by smoking cannabis through a water-pipe. II. A second fractionation step. Experientia 1980 Dec 15; 36(12): 1407-8.
Lubin JH et al. Quantitative evaluation of the radon and lung cancer association in a case control study of Chinese tin miners. Cancer Res 1990; 50:174–80.
Lubin JH, Li JY, Xuan XZ, Cai SK, Luo; Yang QS, Wang JZ, Yang L; Blot WJ. Risk of lung cancer among cigarette and pipe smokers in southern China. Int. J. of Cancer 1992; 51 (3)3: 390-5.
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.
Qiao Y-L, Taylor PR, Yao S-X, et al. Relation of radon exposure and tobacco use to lung cancer among tin miners in Yunnan Province, China. Am J Ind Med. 1989;16 :511 –521.
Savaki HE, Cunha J, Carlini EA et Kephalas TA, Pharmacological activity of three fractions obtained by smoking cannabis through a water-pipe. Bulletin of Narcotics 1976 Apr-Jun; 28(2): 49-56.
Szyper-Kravitz M, Lang R, Manor Y and Lahav M. Early invasive pulmonary aspergillosis in a leukemia patient linked to aspergillus contaminated marijuana smoking. Leuk Lymphoma. 2001 Nov-Dec;42(6):1433-7.
Conflict of Interest:
None declared
Water Pipe (Narghile) Smoking: Response to letter by Chaouachi
14 September 2005
Barry N Knishkowy, adolescent health coordinator Department of Mother, Child and Adolescent Health, Israel Ministry of Health, Yona Amitai
barry.k{at}moh.health.gov.il Barry N Knishkowy, et al.
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
Regrettable lack of scientific methodology in studies on WPS
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
onhclark@aol.com
Conflict of Interest:
None declared
Conflict of Interest on the part of K CHAOUACHI
14 May 2007
Matthew P Gelfand, Undergraduate Student Brown University
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
Re: Conflict of Interest on the part of K CHAOUACHI
21 May 2007
Kamal Chaouachi, Researcher Consultant in Tobacco Control (Paris)
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
The absence of dental stains, heat and ‘smoker’s smell’ encourages Waterpipe Smoking
26 July 2007
Sebastian Thomas, Lecturer Al Fateh University Dental School,Tripoli,Libya., Bashir k.Hush
sebastianhere{at}yahoo.com Sebastian Thomas, et al.
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.
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