ERRORS
Nicotine. Primack et al
state that “blood nicotine of a daily water-pipe user is similar to that of
an individual who smokes 10 cigarettes per day” and cite a “meta-analysis”
carried on by Neergaard et al for this purpose [1][2].
Unfortunately, the latter was criticised in a recent publication on shisha
(hookah, narghile) radioactivity in which the authors warned that Neergaard et
al’ study has actually fuelled a wide confusion in the world [3]. The
first reason is very simple as the studies pooled by Neergaard et al for data
extraction and compilation actually come from India, Lebanon, Koweit, countries
in which the smoking mixture used in the local water pipes –and analysed in the
selected studies- was tumbak and jurak. This is where the main bias lies
as the latter are actually products
known by specialists to be much stronger in nicotine than moassel/tobamel (and
whose related smoking patterns are also completely different), the one actually
used in the USA in general and Arizona in particular [3]. The other
reason for the confusion is a direct consequence of the use of a scientific
nominalism (““waterpipe”” in one word) which has let Neergaard et al believe
(as many other researchers have unfortunately done) that the pipes and the
smoking mixtures were the same in each of the diverse geographical contexts [4].
Primack et al should have kept cautious or asked advice before citing this
source.
Origins. Regarding the
origins of hookah, Primack et al echo an error already pinned down in the
flawed WHO report on ““waterpipe”” tobacco smoking [5]. The
corresponding assumption is unacceptable: “Higher point estimates were
observed for water-pipe tobacco smoking among Pacific Islander students and
Asian American students”. This “may reflect the history of water-pipe
tobacco smoking, as the practice has its roots in the Indian subcontinent as
well as the Middle East"[1]. Not only the corresponding cited
article (by Chattopadhyay) does not mention the Middle East, but the most
serious and solid sources point to an African origin, not an Indian one [5][6].
MISREPRESENTATIONS
Toxicants in
Cigarette Smoke vs. Hookah Smoke. Primack et al state that “water-pipe smoke
contains many of the same toxicants as cigarette smoke”. This is a gross
exaggeration, not to say an untrue one. Indeed, a recent critical analysis
relying on an historic study by chemists and pharmacologists of the Middle East
has emphasised that hookah smoke is actually far less complex than cigarette
smoke. For the first time in 1991, 142 compounds were detected in its smoke
with a filtration rate of 38%. This figure is to be compared to the 4700
substances that have been identified so far in cigarette smoke [4]. A
great part of this confusion is the result of a biased modelling of the hookah
smoking behaviour through a so-called “standardised” “smoking machine [5][7].
Diseases and
Cancer. As for the associated diseases, all the critiques previously published
on this issue can give an idea of the necessity to avoid drawing quick
conclusions. The case of cancer studies is particularly relevant since a team
of Pakistani doctors has recently carried on the first aetiological studies on
hookah smoking and cancer [7]. The findings did not suggest that hookah
health effects are similar or more harmful than those associated with cigarette
smoking. Interestingly, their studies involved exclusive ever hookah smoking
volunteers who had been using a hookah over decades with a bowl usually
containing the tobacco-weight equivalent of 60 cigarettes. In spite of such a
striking aspect, CEA (CarcinoEmbryonic Antigens) levels were found to be much
lower among hookah users than among cigarette smokers [7].
Gateway Hypothesis. Primack et al
state that "an unfortunate
byproduct of this early exposure to tobacco smoking via water pipe may be an
increased likelihood of cigarette smoking. In 1 study of Arab American
adolescents, the odds of experimenting with cigarettes were 8 times greater for
those who had ever smoked tobacco by using a water pipe”[1]. The
supporting bibliographical reference is a study authored by Rice et al, based
on questionnaires that were “adapted” and never scientifically validated for
hookah smoking [8]. This team was urged to make these documents open for
scrutiny so an, exemplary critique can be published; in vain. A promising
original approach was however developed by Hanna et al in the United Kingdom [9].
Unfortunately, it was dismissed, once again with no reason put forward.
Futhermore, it is noteworthy that the previously mentioned scientific nominalism
(““waterpipe”” in one word) is definitely inappropriate for questionnaires in a
language like Arabic (and many others) simply because such a “word” can only be
rendered by vernacular or national names; for instance: hookah, shisha,
narghile, goza, qalyan...
Regarding the
gateway possibility, hookah smoking does not seem to differ from smokeless
tobacco products of the Swedish SNUS type. Independent experts noticed that "the
major ‘‘gateway’’ to adult cigarette smoking is a cigarette itself” and
that “a high risk child would be better off using snus than cigarettes, if
the child is determined to use tobacco"[10]. Interestingly, the
authors of a recent Australian survey involving a large sample, state in their
conclusion 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”[11]. We assume
that this should be good news for all paediatricians of the world.
MISQUOTATIONS
Primack et al
state that "water-pipe tobacco smoking is less physically harsh than
smoking from a cigarette or a cigar (eg, the smoke is cooler and easier to
inhale)”[1]. This is supported by a reference to an experimental
study carried on at the US-American University of Beirut. In fact, this
important aspect was brought out, not by the above, but by other researchers
and a related clarification was repeatedly published in the peer-reviewed
literature [5]. Interestingly,
Primack et al’ statement is in contradiction with Knishkowy and Amitai who
consider this lack of harshness of the smoke as one of the “myths” surrounding
narghile smoking (cf. their list in Table 2)[12]. Finally, Primack et al
credit the same two researchers for mentioning smokeless tobacco in relation to
hookah smoking. This is not true.
Dr Kamal Chaouachi (kamchaAgmail.com)
Tobacco researcher and consultant, DIU Tabacologie, Universite Paris XI.
COMPETING
INTERESTS: I have no competing interests. I have never received direct or indirect
funding neither from pharmaceutical companies (nicotine ‘‘replacement’’
therapies and products) nor from the tobacco industry. Yet, I would consider
with interest any financial or logistic support from any of both.
REFERENCES
[1]
Primack BA, Walsh M, Bryce C, Eissenberg T. Water-Pipe Tobacco Smoking Among
Middle and High School Students in Arizona. Pediatrics. 2009; 123:e282-e288.
[2] Neergaard J, Singh P, Job J, Montgomery S.
Waterpipe smoking and nicotine exposure: a review of the current evidence.
Nicotine Tob Res. 2007;9(10):987–94
[3] 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
Dec;99(12):1808-14.
[4] Chaouachi K. To whom does ‘public health’
belong when it comes to ‘Waterpipe’ Smoking ? Australian and New Zealand
Journal of Public Health 2008; 32 (6): 583.
[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. Journal of Negative Results in Biomedicine 2006
(17 Nov); 5:17.
http://www.jnrbm.com/content/5/1/17
[6] Chattopadhyay A. Emperor Akbar as a healer
and his eminent physicians. Bull Indian Inst Hist Med Hyderabad. 2000;30(2):
151–7.
[7] Sajid KM, Chaouachi K, Mahmood R. Hookah
smoking and cancer. Carcinoembryonic Antigen (CEA) levels in exclusive/ever
hookah smokers. Harm Reduction Journal 2008 24 May;5(19)
http://www.harmreductionjournal.com/content/5/1/19
[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.
[10] Kozlowski LT, O’Connor RJ, Quinio Edwards
B. Some practical points on harm reduction: what to tell your lawmaker and what
to tell your brother about Swedish snus. Tob. Control 2003;12;372-3
[11] 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.
[12] Knishkowy B, Amitai Y: Water-Pipe
(Narghile) Smoking: An Emerging Health
Risk Behavior. Pediatrics 2005, 116: e113-9.
I have no competing interests. I have never received direct or indirect funding neither from pharmaceutical companies (nicotine ‘‘replacement’’ therapies and products) nor from the tobacco industry. Yet, I would consider with interest any financial or logistic support from any of both.
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