Biomarkers of Waterpipe Tobacco Smoke Exposure: A Systematic Review and Meta-Analysis

INTRODUCTION

The prevalence of waterpipe tobacco smoking is increasing globally. Biomarkers of waterpipe tobacco smoke (WTS) exposure are less studied.

AIMS AND METHODS

To identify the types of biomarkers of WTS exposure and estimate changes in biomarker concentrations pre- to post-WTS exposure. PubMed, Embase, Web of Science, CINAHL Plus, PsycINFO, and Cochrane Library were searched for studies up to April 24, 2023. The types of biomarkers were identified. Random-effects models were used to estimate changes in biomarker concentrations pre- to post-WTS exposure.

RESULTS

Seventy-three studies involving 3755 participants exposed to WTS (49% male, mean age: 24.8 years) and 11 types of biomarkers of WTS exposure were identified. The biomarkers included tobacco alkaloids, expired carbon monoxide (eCO), carboxyhemoglobin (COHb), tobacco-specific nitrosamines, volatile organic compounds (VOCs), polycyclic aromatic hydrocarbons (PAHs), heavy metals, unmetabolized VOCs, unmetabolized PAHs, furan metabolites, and heterocyclic aromatic amines. Compared with pre-WTS exposure, eCO (breath; mean difference [MD] 27.00 ppm; 95% confidence interval [CI]: 20.91 to 33.08), COHb (blood; MD 4.30%; 95%CI: 2.57 to 6.03), COHb (breath; MD 7.14%; 95%CI: 4.96 to 9.31), nicotine (blood; MD 8.23 ng/mL; 95%CI: 6.27 to 10.19), and cotinine (urine; MD 110.40 ng/mL; 95%CI: 46.26 to 174.54) significantly increased post-WTS exposure.

CONCLUSIONS

Biomarkers of WTS exposure were systematically identified. The similarity between the biomarkers of WTS exposure and those of cigarette smoke and higher concentrations of some biomarkers post-WTS exposure underscore the need for further research on applying biomarkers in surveillance, interventions, and regulations to mitigate the harms of waterpipe tobacco smoking.

IMPLICATIONS

This study provides the first comprehensive overview of biomarkers investigated and available for assessing WTS exposure and their concentration changes in the human body. Researchers can use biomarkers such as eCO, COHb, nicotine, and cotinine to measure the health risks associated with WTS exposure and objectively evaluate the effectiveness of public health interventions aimed at reducing waterpipe tobacco smoking. Public health policymaking can also be informed through increased biomarker concentrations following WTS exposure, to implement regulations and public health education campaigns on limiting or preventing waterpipe tobacco smoking.

Effects of Waterpipe Smoke Exposure on Experimentally Induced Chronic Kidney Disease in Mice

Tobacco smoking is an independent risk factor in the onset of kidney disease. To date, there have been no reports on the influence of waterpipe smoke (WPS) in experimentally induced chronic kidney disease (CKD) models. We studied the effects and mechanisms of actions of WPS on a mouse model of adenine-induced CKD. Mice fed either a normal diet, or an adenine-added diet and were exposed to either air or WPS (30 min/day and 5 days/week) for four consecutive weeks. Plasma creatinine, urea and indoxyl sulfate increased and creatinine clearance decreased in adenine + WPS versus either WPS or adenine + saline groups. The urinary concentrations of kidney injury molecule-1 and adiponectin and the activities of neutrophil gelatinase-associated lipocalin and N-acetyl-β-D-glucosaminidase were augmented in adenine + WPS compared with either adenine + air or WPS groups. In the kidney tissue, several markers of oxidative stress and inflammation were higher in adenine + WPS than in either adenine + air or WPS groups. Compared with the controls, WPS inhalation in mice with CKD increased DNA damage, and urinary concentration of 8-hydroxy-2-deoxyguanosine. Furthermore, the expressions of nuclear factor κB (NF-κB) and mitogen-activated protein kinases (MAPKs) (ERK and p38) were elevated in the kidneys of adenine + WPS group, compared with the controls. Likewise, the kidneys of adenine + WPS group revealed more marked histological tubular injury, chronic inflammation and interstitial fibrosis. In conclusion, WPS inhalation aggravates kidney injury, oxidative stress, inflammation, DNA damage and fibrosis in mice with adenine-induced CKD, indicating that WPS exposure intensifies CKD. These effects were associated with a mechanism involving NF-κB, ERK and p38 activations.

Central and Peripheral Hemodynamics in Young Adults Who Use Water Pipes and the Acute Effects of Water-Pipe Use

BACKGROUND

Tobacco use via water pipe (commonly referred to as water-pipe smoking [WPS]) is popular among young adults globally and exposes those who smoke to toxicants.

RESEARCH QUESTION

Is WPS associated with impaired measures of arterial function and does WPS acutely impair these measures in young adults?

STUDY DESIGN AND METHODS

We assessed heart rate (HR), brachial and aortic BP, HR-adjusted augmentation index (AI), and carotid-femoral pulse wave velocity (CFPWV) in 62 individuals who use water pipes and 34 individuals who have never used a water pipe recruited from the community (mean age, 22.5 ± 3.0 years; 48% female). Measurements were obtained before and after an outdoor session of WPS among participants who use water pipes and among the control group of participants who have never used a water pipe. Measurements were compared after vs before exposure and between those who use and those who do not use water pipes, adjusting for possible confounders using linear regression.

RESULTS

Participants who use water pipes and control participants had similar demographic characteristics. BP and HR increased acutely after WPS (brachial systolic BP by 4.13 mm Hg [95% CI, 1.91-6.36 mm Hg]; aortic systolic BP by 2.31 mm Hg [95% CI, 0.28-4.33 mm Hg]; brachial diastolic BP by 3.69 mm Hg [95% CI, 1.62-5.77 mm Hg]; aortic diastolic BP by 3.03 mm Hg [95% CI, 0.74-5.33 mm Hg]; and HR by 7.75 beats/min [95% CI, 5.46-10.04 beats/min]), but not in the control group. AI was significantly higher in participants who use water pipes compared with those who do not (9.02% vs 3.06%; P = .03), including after adjusting for BMI and family history of cardiovascular disease (β = 6.12; 95% CI, 0.55-11.69; P = .03) and when assessing habitual tobacco use via water-pipe extent (water pipes used/day × water-pipe use duration) in water-pipe-years (β = 2.51/water-pipe-year; 95% CI, 0.10-4.92/water-pipe-year; P = .04). However, CFPWV was similar in those who use water pipes and those who do not, and AI and CFPWV did not change acutely after WPS.

INTERPRETATION

In apparently healthy young individuals from the community, habitual WPS was associated with increased AI, a predictor of cardiovascular risk, and one WPS session acutely increased HR and brachial and aortic BP.

The cardiovascular consequences of electronic cigarette smoking: a narrative review

INTRODUCTION

E-cigarettes have emerged as a popular alternative to traditional tobacco smoking in recent years. Despite their growing popularity, concerns have arisen regarding the cardiovascular implications of e-cigarette use.

AREAS COVERED

This narrative review aims to highlight the latest evidence on the impact of e-cigarettes on cardiovascular health.

EXPERT OPINION

Numerous studies have demonstrated that e-cigarette use can lead to acute adverse cardiovascular effects. Inhalation of e-cigarette aerosols exposes users to a wide range of potentially harmful substances that have been implicated in critical pathophysiologic pathways of cardiovascular disease, namely endothelial dysfunction, oxidative stress, inflammation, sympathetic overdrive, and arterial stiffness. While long-term epidemiological studies specifically focusing on the cardiovascular effects of e-cigarettes are still relatively scarce, early evidence suggests a potential association between e-cigarette use and an increased risk of adverse cardiovascular events. However, it is essential to recognize that e-cigarettes are relatively new products, and the full extent of their long-term cardiovascular impact has not been fully elucidated. In the meantime, promoting tobacco cessation strategies that are evidence-based and regulated, along with rigorous monitoring of e-cigarette use patterns and associated health outcomes, are essential steps in safeguarding cardiovascular health in the face of this emerging public health challenge.

Waterpipe Use and Its Cardiovascular Effects: A Systematic Review and Meta-Analysis of Case-Control, Cross-Sectional, and Non-Randomized Studies

Approximately 100 million people globally smoke cigarettes, making it a significant and quickly spreading global tobacco epidemic. Substance use disorders are frequently evaluated by non-randomized studies. Tobacco use and its impacts on the cardiovascular system were the subjects of a comprehensive search across five electronic databases: Cochrane, MEDLINE, Scopus, Embase, and PubMed. The findings demonstrated that waterpipe smokers in comparison to non-smokers have immediate elevations in heart rate and blood pressure, lower levels of high-density lipoprotein, higher levels of low-density lipoprotein, higher levels of triglycerides, higher levels of fasting blood glucose, and a higher heart rate. Users of waterpipes and cigarettes had similar average heart rates, blood pressure, and lipid levels, with the exception that waterpipe smokers had greater total cholesterol. Smoking a waterpipe has significant negative effects on the cardiovascular system comparable to cigarette smoking, and non-randomized studies proved to yield substantial evidence related to its cardiovascular effects. Such study designs can be used to evaluate substance use and its cardiovascular impact.

Waterpipe smoke inhalation potentiates cardiac oxidative stress, inflammation, mitochondrial dysfunction, apoptosis and autophagy in experimental hypertension

Cigarette smoking worsens the health of hypertensive patients. However, less is known about the actions and underlying mechanisms of waterpipe smoke (WPS) in hypertension. Therefore, we evaluated the effects of WPS inhalation in mice made hypertensive (HT) by infusing angiotensin II for six weeks. On day 14 of the infusion of angiotensin II or vehicle (normotensive; NT), mice were exposed either to air or WPS for four consecutive weeks. Each session was 30 min/day and 5 days/week. In NT mice, WPS increased systolic blood pressure (SBP) compared with NT air-exposed group. SBP increase was elevated in HT+WPS group versus either HT+air or NT+WPS. Similarly, the plasma levels of brain natriuretic peptide, C-reactive protein, 8-isoprostane and superoxide dismutase were increased in HT+WPS compared with either HT+air or NT+WPS. In the heart tissue, several markers of oxidative stress and inflammation were increased in HT+WPS group vs the controls. Furthermore, mitochondrial dysfunction in HT+WPS group was more affected than in the HT+air or HT+WPS groups. WPS inhalation in HT mice significantly increased cardiac DNA damage, cleaved caspase 3, expression of the autophagy proteins beclin 1 and microtubule-associated protein light chain 3B, and phosphorylated nuclear factor κ B, compared with the controls. Compared with HT+air mice, heart histology of WPS-exposed HT mice showed increased cardiomyocyte damage, neutrophilic and lymphocytic infiltration and focal fibrosis. We conclude that, in HT mice, WPS inhalation worsened hypertension, cardiac oxidative stress, inflammation, mitochondrial dysfunction, DNA damage, apoptosis and autophagy. The latter effects were associated with a mechanism involving NF-κB activation.

The effect of emerging tobacco related products and their toxic constituents on thrombosis

Although conventional cigarette smoking is declining, emerging tobacco related products (ETRPs) are currently gaining ground, especially among the youth. These products include electronic cigarettes, waterpipes/hookah, cigars/cigarillo, smokeless tobacco, and heat-not-burn cigarettes. The observed increase in the use of ETRPs is multifactorial and complex but appears to be mainly driven by efforts from the major tobacco companies to reinvent themselves, and present more appealing and allegedly safe(r) tobacco products. However, it is becoming apparent that these products produce substantial amounts of toxic chemicals, many of which have been shown to exert negative health effects, including in the context of the cardiovascular system. Thus, there has been research efforts, albeit limited in general, to characterize the health impact of these products on occlusive/thrombotic cardiovascular diseases (CVD). In this review, we will discuss the potential impact of ETRPs on thrombosis-based CVD. Specifically, we will review how these products and the major chemicals they produce and/or emit can trigger key players in the process of thrombosis, namely inflammation, oxidative stress, platelets, coagulation, and the vascular endothelium, and the relationship between these effects.

Waterpipe smoke-induced hypercoagulability and cardiac injury in mice: Influence of cessation of exposure

Waterpipe tobacco smoking has gained worldwide popularity, particularly among youths. Several clinical and experimental studies have reported that waterpipe smoking (WPS) injures the cardiovascular system. However, the impact of smoking cessation (CS) on the cardiovascular toxicity induced by WPS received scant attention. Hence, we assessed, in C57BL/6 mice, the cardiovascular effects of WPS exposure for 3 months followed by 3 months of SC, as compared with mice exposed for either 3 months to WPS or air (control). WPS exposure induced hypertension, prothrombotic events both in vivo and in vitro and increased the plasma concentrations of tissue factor, fibrinogen and plasminogen activator inhibitor-1. These effects were significantly alleviated by SC. In heart tissue, the levels of troponin I, creatine kinase, lipid peroxidation, 8-isoprostane, tumor necrosis factor α, inteleukin 6, DNA damage and cleaved caspase-3 were significantly increased by WPS exposure. These actions were significantly reduced in the group of mice exposed to WPS followed by SC. Similarly, the increase in the level of nuclear factor κ-β induced by WPS exposure was significantly mitigated by SC. Immunohistochemical analysis of the hearts showed that WPS exposure increased the expression of nuclear factor erythroid-derived 2-like 2 by cardiomyocytes. The latter effect was significantly reduced by SC. Taken together, our data show that SC is associated with amelioration of WPS induced hypertension, prothrombotic events and cardiac oxidative stress, inflammation, DNA damage and apoptosis.

Waterpipe smoking: a review of pulmonary and health effects

Waterpipe smoking is an old form of tobacco smoking, originating in Persia and the Middle East. The popularity of the waterpipe is increasing worldwide, particularly among young adults, and there are widespread misconceptions regarding its negative health effects. The inhaled smoke of the waterpipe contain several toxic and hazardous materials including nicotine, tar, polyaromatic hydrocarbons and heavy metals, all of which are proven to be related to lung diseases and cancer. Regular waterpipe smoking is associated with respiratory symptoms, a decrease in pulmonary function and increased risk for lung disease such as COPD. Additional negative health effects include increased risk for arterial stiffness, ischaemic heart disease and several cancer types including lung cancer. This review summarises the negative health effects of waterpipe smoking, with emphasis on cardiorespiratory complications. Increased awareness and knowledge amongst healthcare professionals will hopefully help identify waterpipe smokers and promote patient education. Applying World Health Organization (WHO) regulations will provide a synergistic effect in reducing waterpipe use and associated disease.

Prospective estimation of the age of initiation of hookah use among youth: Findings from the Population Assessment of Tobacco and Health (PATH) study waves 1-4 (2013-2017)

OBJECTIVE

This study reports the prospectively estimated age of initiation of susceptibility to, ever, past 30-day, and fairly regular hookah use.

DESIGN

Secondary data analyses of the first four waves (2013-2017) of the PATH study, a nationally representative longitudinal cohort study of US youth (ages 12-17).

METHODS

Youth who were never hookah users at their first wave of participation were identified (n = 16,678; N = 31,136,834). Four outcomes were analyzed, age of first report of: (i) susceptibility to use, (ii) ever use, (iii) past 30-day use, and (iv) fairly regular hookah use. The age of hookah initiation of each outcome was estimated. Weighted interval censoring survival analyses and Cox regression models were conducted to estimate the age of initiation of each hookah use outcome, and to estimate differences in age of initiation by sex and by race, respectively.

RESULTS

Around 11% of youth were classified as susceptible to hookah use by 13 years of age, 8% reported initiating ever hookah use by age 17, almost 10% reported initiating past 30-day hookah use by age 19, and 3% reported initiating fairly regular hookah use by age 20. Females and Hispanics were at higher risk of becoming susceptible to and ever hookah use at earlier ages compared to males and Non-Hispanic White youth.

CONCLUSION

Education, communication campaigns, and proven culturally targeted tobacco interventions that reach youth at ages before they first become susceptible or start using hookah use are needed to prevent the onset of hookah use among vulnerable youth.

The Chronic Effects of Narghile Use on Males' Cardiovascular Response During Exercise: A Systematic Review

Narghile use has regained popularity throughout the world. Public opinion misjudges its chronic harmful effects on health, especially on the cardiovascular system. This systematic review aimed to evaluate the chronic effects of narghile use on cardiovascular response during exercise. It followed the preferred reporting items for systematic reviews guidelines. Original articles from PubMed and Scopus published until January 31, 2020, written in English, and tackling the chronic effects of narghile use on human cardiovascular response during exercise were considered. Five studies met the inclusion criteria. Only males were included in these studies. They were published between 2014 and 2017 by teams from Tunisia (n = 4) and Jordan (n = 1). One study applied the 6-min walk test, and four studies opted for the cardiopulmonary exercise test. Narghile use was associated with reduced submaximal (e.g., lower 6-min walk distance) and maximal aerobic capacities (e.g., lower maximal oxygen uptake) with abnormal cardiovascular status at rest (e.g., increase in heart rate and blood pressures), at the end of the exercise (e.g., lower heart rate, tendency to chronotropic insufficiency) and during the recovery period (e.g., lower recovery index). To conclude, chronic narghile use has negative effects on cardiovascular response to exercise with reduced submaximal and maximal exercise capacities.

Effects of tobacco cigarettes, e-cigarettes, and waterpipe smoking on endothelial function and clinical outcomes

Tobacco smoking is a leading cause of non-communicable disease globally and is a major risk factor for cardiovascular disease (CVD) and lung disease. Importantly, recent data by the World Health Organizations (WHO) indicate that in the last two decades global tobacco use has significantly dropped, which was largely driven by decreased numbers of female smokers. Despite such advances, the use of e-cigarettes and waterpipes (shisha, hookah, narghile) is an emerging trend, especially among younger generations. There is growing body of evidence that e-cigarettes are not a harm-free alternative to tobacco cigarettes and there is considerable debate as to whether e-cigarettes are saving smokers or generating new addicts. Here, we provide an updated overview of the impact of tobacco/waterpipe (shisha) smoking and e-cigarette vaping on endothelial function, a biomarker for early, subclinical, atherosclerosis from human and animal studies. Also their emerging adverse effects on the proteome, transcriptome, epigenome, microbiome, and the circadian clock are summarized. We briefly discuss heat-not-burn tobacco products and their cardiovascular health effects. We discuss the impact of the toxic constituents of these products on endothelial function and subsequent CVD and we also provide an update on current recommendations, regulation and advertising with focus on the USA and Europe. As outlined by the WHO, tobacco cigarette, waterpipe, and e-cigarette smoking/vaping may contribute to an increased burden of symptoms due to coronavirus disease 2019 (COVID-19) and to severe health consequences.

A Review of the Pulmonary and Health Impacts of Hookah Use

Hookah is a single-stemmed or multistemmed instrument for vaporizing and smoking flavored tobacco, whose smoke is passed through a water basin before inhalation. The use of hookah dates back centuries and is believed to have originated in India during the reign of Akbar the Great or the Safavid dynasty of Persia. Outside its native region, hookah smoking has gained popularity throughout the world, especially among younger people. There is generally a misconception among hookah users that it is less addictive than combustible cigarette smoking and that there is little to no nicotine content in hookah, with some even believing that certain additives impart health benefits. Although studies investigating the health hazards of hookah are rather limited, the inhaled smoke contains large quantities of nicotine, tar, carbon monoxide, polyaromatic hydrocarbons, heterocyclic compounds, carboxylic compounds, and various inorganic compounds such as heavy metals, all of which are found in combustible cigarette smoking. Regular hookah use is associated with an increased risk of obstructive lung disease as well as lung cancer and malignancies of the head and neck. This narrative review summarizes the available data on the health hazards of hookah, with an emphasis on pulmonary complications. Increased knowledge and awareness of hookah smoking among healthcare providers can potentially lead to better patient education and identification of at-risk populations.

Water Pipe (Hookah) Smoking and Cardiovascular Disease Risk: A Scientific Statement From the American Heart Association

Tobacco smoking with a water pipe or hookah is increasing globally. There are millions of water pipe tobacco smokers worldwide, and in the United States, water pipe use is more common among youth and young adults than among adults. The spread of water pipe tobacco smoking has been abetted by the marketing of flavored tobacco, a social media environment that promotes water pipe smoking, and misperceptions about the addictive potential and potential adverse health effects of this form of tobacco use. There is growing evidence that water pipe tobacco smoking affects heart rate, blood pressure regulation, baroreflex sensitivity, tissue oxygenation, and vascular function over the short term. Long-term water pipe use is associated with increased risk of coronary artery disease. Several harmful or potentially harmful substances present in cigarette smoke are also present in water pipe smoke, often at levels exceeding those found in cigarette smoke. Water pipe tobacco smokers have a higher risk of initiation of cigarette smoking than never smokers. Future studies that focus on the long-term adverse health effects of intermittent water pipe tobacco use are critical to strengthen the evidence base and to inform the regulation of water pipe products and use. The objectives of this statement are to describe the design and operation of water pipes and their use patterns, to identify harmful and potentially harmful constituents in water pipe smoke, to document the cardiovascular risks of water pipe use, to review current approaches to water pipe smoking cessation, and to offer guidance to healthcare providers for the identification and treatment of individuals who smoke tobacco using water pipes.

Acute effects of e-cigarette vaping on pulmonary function and airway inflammation in healthy individuals and in patients with asthma

BACKGROUND AND OBJECTIVE

The acute effects of e-cigarettes have not been scientifically demonstrated yet. The aim of this study was to assess the acute changes in pulmonary function and airway inflammation in patients with asthma after vaping one e-cigarette.

METHODS

Twenty-five smokers suffering from stable moderate asthma according to GINA guidelines with no other comorbidities and 25 healthy smokers matched with the baseline characteristics of the asthmatic patients were recruited. PFT, IOS, FeNO and EBC were performed before and after vaping one e-cigarette with nicotine. pH and concentrations of IL-1β, IL-4, IL-5, IL-6, IL-8, IL-10, IL-13, IL-17A, TNF-α, ISO8 and LTB4 were measured in EBC.

RESULTS

FFEV1/FVC ratio and PEF were reduced in asthmatic patients after e-cigarette. Z5Hz and R5Hz, R10Hz and R20Hz increased in both groups. FeNO and EBC pH increased by 3.60 ppb (P = 0.001) and 0.15 (P = 0.014) in asthmatic patients after e-cigarette, whereas they decreased in control group by 3.28 ppb (P < 0.001) and 0.12 (P = 0.064), respectively. The concentrations of IL-10, TNF-α and ISO8 in EBC increased in asthmatic patients after e-cigarette and the changes in concentrations of IL-1β and IL-4 differed significantly between the two groups.

CONCLUSION

E-cigarette vaping resulted in acute alteration of both pulmonary function and airway inflammation in stable moderate asthmatic patients.

Systemic Inflammatory Markers Among Waterpipe Smokers, Cigarette Smokers, and Nonsmokers

OBJECTIVE

To determine the levels of neutrophil to lymphocyte ratio (NLR) and platelet to lymphocyte ratio (PLR) among exclusive groups of waterpipe (WP) smokers, cigarette smokers, and nonsmokers.

METHODS

This cross-sectional study was conducted among adults, apparently healthy individuals, aged between 18 and 40 years of either gender. NLR and PLR as measures of systemic inflammation were studied in association with individuals' sociodemographic, health, and tobacco use related characteristics. The results of linear and logistic regression models were reported as crude and adjusted beta coefficients and odds ratios with 95% confidence intervals (CIs).

RESULTS

Out of 190 participants, 34.2% (n = 65) exclusively smoked WP, 32.6% (n = 62) smoked cigarettes, and 33.2% (n = 63) were nonsmokers. The mean NLR and PLR were significantly higher among WP smokers when compared with nonsmokers; however, the comparison between WP smokers and cigarette smokers for both NLR and PLR was not statistically significant. The odds of raised NLR was 4.40 times higher (AOR = 4.40, 95% CI = 1.97, 9.85), and the odds of raised PLR was 3.48 times higher (AOR = 3.48, 95% CI = 1.60, 7.57) for WP smokers compared to nonsmokers.

CONCLUSIONS

WP smoking has a significant association with systemic inflammation as measured by NLR and PLR. The study and existing evidence implicate an urging need to regulate WP industry and its policies.

Waterpipe Tobacco Smoke Inhalation Triggers Thrombogenicity, Cardiac Inflammation and Oxidative Stress in Mice: Effects of Flavouring

The consumption of water-pipe smoking (WPS) has been promoted by the use of flavoured tobacco. However, little is known about the impact of flavouring on the cardiovascular toxicity induced by WPS inhalation. Here, we compared the cardiovascular effects and underlying mechanism of actions of plain (P) (unflavoured) versus apple-flavoured (AF) WPS (30 minutes/day, 5 days/week for 1 month) in mice. Control mice were exposed to air. Both P- and AF-WPS inhalation induced an increase in systolic blood pressure, thrombogenicity and plasma concentration of fibrinogen and von Willebrand factor. In heart homogenates, AF-WPS inhalation caused an increase of 8-isoprostane and a decrease in the levels of reduced glutathione (GSH) and superoxide dismutase (SOD). Nevertheless, P-WPS decreased only the activity of SOD. The concentrations of tumour necrosis factor α and interleukin 1β were increased only in heart homogenates of mice exposed to AF-WPS. Although both P- and AF-WPS increased the concentration of troponin I in heart homogenates and induced DNA damage, the concentration of cleaved caspase 3 was only increased in mice exposed to AF-WPS. Immunohistochemical analysis of the hearts showed that both P- and AF- WPS inhalation decreased the expression of SOD. Moreover, the expression of nuclear factor erythroid-derived 2-like 2 at nuclear level in the heart was higher in both AF-WPS and P-WPS compared with control group, and the effect observed in AF-WPS group was more significant than that seen in P-WPS group. Likewise, the concentration of heme oxygenase-1 was significantly increased in both P-WPS and AF-WPS groups compared with control group, and the effect seen in AF-group was higher than that observed in P-WPS group. In conclusion, our findings showed that both P- and AF-WPS induce thrombogenicity and cardiac injury, and that this toxicity is potentiated by the presence of flavouring.

Evidence of compensation among waterpipe smokers using harm reduction components

OBJECTIVES

We examined two waterpipe tobacco smoking components advertised to reduce harm to determine if they result in lower levels of biomarkers of acute exposure.

METHODS

We conducted a crossover study of 34 experienced waterpipe smokers smoking a research-grade waterpipe in three configurations ad libitum in a controlled chamber: control (quick-light charcoal), electric (electric heating) and bubble diffuser (quick-light charcoal and bubble diffuser). We collected data on smoking topography, environmental carbon monoxide (CO), subjective effects, heart rate, plasma nicotine and exhaled CO and benzene.

RESULTS

Smokers' mean plasma nicotine, heart rate, and exhaled benzene and CO boost were all significantly lower for electric compared with control. However, smokers puffed more intensely and took significantly more and larger volume puffs for a larger total puffing volume (2.0 times larger, p<0.0001) when smoking electric; machine yields indicate this was likely due to lower mainstream nicotine. Smokers rated electric smoking experience less satisfying and less pleasant. For charcoal heating, the mean mass of CO emitted into the chamber was ~1 g when participants smoked for a mean of 32 minutes at a typical residential ventilation rate (2.3 hr-1).

CONCLUSION

Waterpipe smokers engaged in compensation (i.e., increased and more intense puffing) to make up for decreased mainstream nicotine delivery from the same tobacco heated two ways. Waterpipe components can affect human puffing behaviours, exposures and subjective effects. Evidence reported here supports regulation of waterpipe components, smoking bans in multifamily housing and the use of human studies to evaluate modified or reduced risk claims.

Substantial Toxic Effect of Water-Pipe Smoking on the Early Stage of Embryonic Development

Background

Water-pipe smoking (WPS) is the most widespread tobacco use in the Middle-East, and is rapidly spreading globally. Smoke from WP contains most of the compounds present in cigarette smoke, although in different proportions. WPS is associated with the risk of several human diseases; however, its impact on the early stage of normal development has not been investigated yet. Thus, in this investigation, we assess the effect of WPS on the embryo at the early stage of development.

Methods

Chicken embryos at 3 days of incubations were used in this study. Meanwhile, we explored the outcome of WPS on angiogenesis using the chorioallantoic membrane (CAM) of the chicken embryos. Finally, quantitative real-time polymerase chain reaction was used to study the regulation of some key control genes of cell proliferation, apoptosis, and migration.

Results

Our data reveal that WPS inhibits angiogenesis of the CAM and in embryos in comparison with their matched controls; in addition, WPS-exposed embryos show slight reduction in their sizes. We also noted that around 80% of WPS-exposed embryos die before 10 days of incubation. More significantly, WPS induces upregulations of BCL-2, Caspase-8, ATF-3, INHIB-A, and Cadherin 6 genes, which are important key regulators of cell apoptosis, proliferation, and migration.

Conclusion

Our data reveal, for the first time, that WPS has very toxic effects during the early stage of embryogenesis. Thus, we believe that further studies are required to elucidate the pathogenic effect of WPS on human health especially on the embryo at the early stage of its development.

Implications

This investigation addresses an important gap on the outcome of WPS during the early stage of embryogenesis. Data of this study point out that WPS can have a very toxic effect on the embryo at this stage. Additionally, results from this report display for the first time that WPS can damage normal angiogenesis of the embryo thus provoking a significant number of embryonic death. Moreover, this study reveals that this effect can occur via the deregulation of several genes related to cell apoptosis, proliferation, and migration.

The Effect of a 30-Min Water-Pipe Smoking Session on Cognitive Measures and Cardio-Pulmonary Parameters

Introduction

One session of water-pipe tobacco smoking (WPS) can increase carboxyhemoglobin (COHb) to levels comparable to those reported in carbon monoxide poisoning, which may cause memory impairment and confusion.

Methods

A prospective study evaluating healthy volunteers pre- and post-30 min of WPS session. Primary outcome parameters were executive cognitive measures [digit span test and Paced Auditory Serial Addition Test (PASAT)]. The effect of repeated cognitive testing 30 min apart without WPS was evaluated in age- and sex-matched healthy volunteers. Secondary outcome parameters included cardio-pulmonary, COHb, serum nicotine, and cytokine changes.

Results

Thirty-five subjects aged 25.6 ± 4.5 years smoked water-pipe for a 30-min session. Control group included 20 subjects aged 25.2 ± 5.1 years. Digit span test median score decreased after WPS (16 and 15, respectively, p = .003), insignificant decrease in controls. Median PASAT score increased after WPS (49 and 52, respectively, p = .009); however, a much larger significant increase was observed in controls (p ≤ .001). One WPS session resulted in significant increases in heart and respiratory rates and significant decrease in FEF25–75%. Post WPS, median COHb levels increased (from 2.2% to 10.7%, p &lt; .0001) as did median serum nicotine levels (from 1.2 to 26.8 ng/mL, p &lt; .0001). Serum cytokines levels: IL-2 and IL-6 increased (p &lt; .0001 for each), and IL-10 and IL-5 decreased (p &lt; .0001 and p = .04, respectively).

Conclusions

One session of WPS resulted in significant negative effects on cognitive executive measures, significant increases in COHb and serum nicotine levels, and significant changes in serum cytokines. Our findings call for increasing awareness towards the possible consequences of cognitive alterations following a 30-min session of WPS.

Implications

One 30-min session of water-pipe smoking resulted in negative effects on executive cognitive measures, increased carboxyhemoglobin and serum nicotine, and significant changes in serum cytokine levels. This study adds to the accumulating evidence on the harmful effects of water-pipe smoking, a growing epidemic, and calls for awareness of its possible consequences of acute cognitive alterations.

Water pipe smoking as a cause of secondary erythrocytosis

Water pipe (WP) smoking has become very popular in European countries. A 27-year-old male patient was referred to our clinic with erythrocytosis of unknown origin. His self-reported history included almost daily WP smoking since the age of 14 years. At presentation haemoglobin, haematocrit (Hct) and carboxy-haemoglobin (CO-Hb) levels were elevated to 19.7 g/dl, 54% and 15.4%, respectively. Erythrocytosis was completely reversible upon cessation of WP smoking. Upon follow-up, haemoglobin, Hct and CO-Hb levels undulated according to the intensity of WP usage. Our report shall raise awareness among physicians for WP smoking as a possible cause of secondary erythrocytosis, particularly among younger adults, and provide guidance for the clinical management.

The Association of Water-Pipe Smoking and Coronary Artery Calcium in a Community-Based Sample

BACKGROUND

Water-pipe smoking is increasing in popularity, driven partly by a perception of reduced harm compared with cigarette smoking. This study evaluates the association of water-pipe smoking with coronary artery calcium (CAC), a marker of coronary heart disease (CHD) risk, in a community-based sample.

METHODS

A total of 175 exclusive water-pipe smokers and 170 nonsmokers, ≥ 35 years of age, were recruited from the community in Lebanon and Qatar. Water-pipe smoking was assessed using a validated questionnaire. CAC score was assessed using multidetector CT scan. The association of water-pipe smoking with the presence and extent of CAC was evaluated using regression analyses adjusted for CHD risk factors.

RESULTS

CAC was present in 41% of water-pipe smokers vs 28% of nonsmokers (P = .01), with an average CAC score ± SD of 90.6 ± 400.3 Agatston units (AUs) in water-pipe smokers and 52.4 ± 218.6 AUs in nonsmokers. In adjusted analyses, water-pipe smokers had significantly higher adjusted odds of having CAC (OR = 2.20; 95% CI, 1.20-4.01; P = .01) and being in the high CHD risk category defined by CAC > 300 AUs (OR = 3.41; 95% CI, 1.08-10.77; P = .04) or CAC > 75% of age, sex, and race-predicted (OR = 3.11; 95% CI, 1.55-6.24; P = .001) than nonsmokers. CAC extent was significantly associated with water-pipe smoking extent measured by smoking duration (β = 0.17/year; 95% CI, 0.05-0.29; P = .004) or the product of smoking duration and the number of water pipes smoked daily (β = 0.04/water-pipe-year; 95% CI, 0.003-0.07; P = .03).

CONCLUSIONS

Exclusive water-pipe smoking was associated with the presence and extent of CAC, with twice the risk of having CAC and three times the risk of being in the high CHD risk category while accounting for other risk factors.

Waterpipe Tobacco Smoking: A Mini-review

The waterpipe tobacco smoking is an ancient form of smoking that is present in the society since centuries. The majority of consumers of this exotic activity are still unaware of the serious consequences that this type of smoking has on the health of the smoker. The paucity of data related to the prevalence and extent of this habit in the society is still not available. In this present short review, the authors try to highlight this serious health issue and suggest preventive measures.

Biomarkers of Exposure to Secondhand and Thirdhand Tobacco Smoke: Recent Advances and Future Perspectives

Smoking is the leading preventable disease worldwide and passive smoking is estimated to be the cause of about 1.0% of worldwide mortality. The determination of tobacco smoke biomarkers in human biological matrices is key to assess the health effects related to the exposure to environmental tobacco smoke. The biomonitoring of cotinine, the main nicotine metabolite, in human biofluids-including urine, serum or saliva-has been extensively used to assess this exposure. However, the simultaneous determination of cotinine together with other tobacco biomarkers and the selection of alternative biological matrices, such as hair, skin or exhaled breath, would enable a better characterization of the kind and extent of tobacco exposure. This review aims to perform a critical analysis of the up-to-date literature focused on the simultaneous determination of multiple tobacco smoke biomarkers studied in different biological matrices, due to the exposure to secondhand smoke (SHS) and thirdhand smoke (THS). Target biomarkers included both tobacco-specific biomarkers-nicotine and tobacco specific nitrosamine biomarkers-and tobacco-related biomarkers, such as those from polycyclic aromatic hydrocarbons, volatile organic compounds, metals and carbon monoxide. To conclude, we discuss the suitability of determining multiple biomarkers through several relevant examples of SHS and THS exposure.

Water-pipe smoking promotes epithelial-mesenchymal transition and invasion of human breast cancer cells via ERK1/ERK2 pathways

Background

With the increasing popularity of water-pipe smoking (WPS), it is critical to comprehend how WPS may affect women's health. The main goal of this study is to identify the potential outcome of WPS on human breast cancer progression.

Methods

Two breast cancer cell lines, MCF7 and BT20, were used in this investigation. We explored the outcome of WPS on cell morphology and cell invasion using inverted microscope and Biocoat Matrigel invasion chambers. On the other hand, Western blot was employed to study the expression patterns of key control genes of cell adhesion and invasion.

Results

Our data reveal that WPS induces epithelial-mesenchymal transition (EMT) of MCF7 and BT20 breast cancer cell lines; thus, WPS enhances cell invasion ability of both cell lines in comparison with their matched controls. More significantly, WPS provokes a down- and up-regulation of E-cadherin and focal adhesion kinase (FAK), respectively, which are important key regulators of cancer progression genes. Finally, our data point out that WPS incites the activation of Erk1/Erk2, which could be behind the stimulation of EMT and invasion as well as the deregulation of E-cadherin and FAK expression.

Conclusion

Our data show, for the first time, that WPS initiates EMT and stimulates cell invasion of breast cancer cells, which could incite metastatic development in breast cancer patients. Thus, we believe that further studies, both in vitro and in vivo, are required to elucidate the pathogenic outcome of WPS on cancer progression of several human carcinomas including breast.

Effect of prenatal waterpipe tobacco smoke on airway inflammation in murine model of asthma of adult offspring mice

OBJECTIVE

Worldwide popularity of waterpipe tobacco smoking has increased, including in pregnant women. This study investigates the effect of prenatal waterpipe tobacco smoke (WTS) exposure on airway inflammation in a murine model of asthma of adult offspring mice.

MATERIALS AND METHODS

Pregnant BALB/c mice were exposed to fresh air or WTS, using a whole-body exposure system that mimics human use during WTS. Adult male offspring mice were divided into; (1) control (prenatal fresh air, postnatal ovalbumin sensitization and saline challenge), (2) postnatal Ova S/C (prenatal fresh air, postnatal ovalbumin sensitization and challenge (Ova S/C)), (3) prenatal WTS (prenatal WTS, postnatal ovalbumin sensitization and saline challenge) and (4) prenatal WTS + postnatal Ova S/C. Cells from the bronchoalveolar lavage fluid, cytokines, and oxidative stress markers (superoxide dismutase (SOD), catalase, glutathione peroxidase (GPx) and thiobarbituric acid reactive substances (TBARS)) from lung homogenates were evaluated.

RESULTS

Prenatal WTS increased recruitment of cells in lungs and levels of SOD and catalase when compared to unexposed offspring's. The levels of cytokines, GPx and TBARS were not affected by prenatal WTS. Prenatal WTS exposure and postnatal Ova S/C increased airway inflammation and activity of SOD compared to control and Ova S/C mice and reduced IL-18 levels compared to Ova S/C mice.

DISCUSSION AND CONCLUSIONS

Prenatal exposure to WTS induced airway inflammation, further enhanced by a murine model of asthma in adult offspring. Prenatal exposure to WTS adversely affects the lung function of the offspring and careful strategies for increasing public awareness regarding the harmful effects of WTS during pregnancy is important.

Cardiovascular Effects of Hookah Smoking: Potential Implications for Cardiovascular Risk

Introduction

Smoking is a major cause of cardiovascular morbidity and mortality worldwide. Hookah (ie, waterpipe) smoking is a centuries-old revived yet understudied global epidemic of tobacco use. Because of the traditional set-up of a hookah-pipe, in addition to inhaling tobacco-combustion products, smokers are also exposed to large amounts of charcoal combustion products from the burning charcoal briquettes used to heat the hookah flavored tobacco. Despite being heavily advertised and actively glamorized in the mass media as a healthier tobacco alternative, the toxicological constituents of hookah smoke—including nicotine, carbon monoxide, particulates, oxidants, heavy metals, phenols and flavorants—indicate the potential to cause adverse cardiovascular events.

Methods

Herein, we review evidence on hookah smoke toxicological constituents, cardiovascular effects and potential mechanisms by which hookah smoke aerosol could cause cardiovascular disease.

Results

The evidence reviewed here indicates that contrary to the widespread popular belief that hookah is a healthier tobacco alternative, the constituents of hookah smoke aerosol contains similar chemicals compared to cigarette smoke, many of which are known to be harmful to cardiovascular health and mediated by similar pathophysiologic processes. Because the burning charcoal briquettes are a unique source of toxicant emissions specific to hookah smoking, some constituents differ in their quantities from cigarettes with some of their cardiovascular effects unknown.

Conclusions

To date, much more is known about the constituents and their toxicology than about the effects of hookah smoking on human cardiovascular health. Further research on long-term consequences of hookah use is needed.

Implications

This review provides an overview on the potential impact of hookah smoking on cardiovascular health. Readers will gain an insight into evidence on its toxicological constituents, human health effects, and pathophysiological mechanisms by which hookah smoking might cause cardiovascular disease. The review also highlights current research gaps regarding the cardiovascular consequences of hookah smoking, specifically the long-term consequences in the United States and Europe among flavored-hookah tobacco users.

Exercise Training Mitigates Water Pipe Smoke Exposure-Induced Pulmonary Impairment via Inhibiting NF-κB and Activating Nrf2 Signalling Pathways

Water pipe smoking is a tobacco smoking method commonly used in Eastern countries and is gaining popularity in Europe and North America, in particular among adolescents and young adults. Several clinical and experimental studies have reported that exposure to water pipe smoke (WPS) induces lung inflammation and impairment of pulmonary function. However, the mechanisms of such effects are not understood, as are data on the possible palliative effect of exercise training. The present study evaluated the effects of regular aerobic exercise training (treadmill: 5 days/week, 40 min/day) on subchronic exposure to WPS (30 minutes/day, 5 days/week for 2 months). C57BL/6 mice were exposed to air or WPS with or without exercise training. Airway resistance measured using forced oscillation technique was significantly and dose-dependently increased in the WPS-exposed group when compared with the air-exposed one. Exercise training significantly prevented the effect of WPS on airway resistance. Histologically, the lungs of WPS-exposed mice had focal moderate interstitial inflammatory cell infiltration consisting of neutrophil polymorphs, plasma cells, and lymphocytes. There was a mild increase in intra-alveolar macrophages and a focal damage to alveolar septae in some foci. Exercise training significantly alleviated these effects and also decreased the WPS-induced increase of tumor necrosis factor α and interleukin 6 concentrations and attenuated the increase of 8-isoprostane in lung homogenates. Likewise, the lung DNA damage induced by WPS was significantly inhibited by exercise training. Moreover, exercise training inhibited nuclear factor kappa-B (NF-κB) expression induced by WPS and increased that of nuclear factor erythroid 2-related factor 2 (Nrf2). Our findings suggest that exercise training significantly mitigated WPS-induced increase in airway resistance, inflammation, oxidative stress, and DNA damage via mechanisms that include inhibiting NF-κB and activating Nrf2 signalling pathways.

Acrolein Exposure in Hookah Smokers and Non-Smokers Exposed to Hookah Tobacco Secondhand Smoke: Implications for Regulating Hookah Tobacco Products

Introduction

Acrolein is a highly ciliatoxic agent, a toxic respiratory irritant, a cardiotoxicant, and a possible carcinogen present in tobacco smoke including hookah tobacco.

Methods

105 hookah smokers and 103 non-smokers attended exclusively hookah smoking social events at either a hookah lounge or private home, and provided urine samples the morning of and the morning after the event. Samples were analyzed for 3-hydroxypropylmercapturic acid (3-HPMA), a metabolite of acrolein.

Results

Geometric mean (GM) urinary 3-HPMA levels in hookah smokers and non-smokers exposed to secondhand smoke (SHS) increased significantly, 1.41 times, 95% CI = 1.15 to 1.74 and 1.39 times, 95% CI = 1.16 to 1.67, respectively, following a hookah social event. The highest increase (1.68 times, 95% CI = 1.15 to 2.45; p = 0.007) in 3-HPMA post a hookah social event was among daily hookah smokers (GM, from 1991 pmol/mg to 3348 pmol/mg). Pre-to-post event change in urinary 3-HPMA was significantly positively correlated with pre-to-post event change in urinary cotinine among hookah smokers at either location of hookah event, (ρ = 0.359, p = 0.001), and among non-smokers in hookah lounges (ρ = 0.369, p = 0.012).

Conclusions

Hookah tobacco smoke is a source of acrolein exposure. Findings support regulating hookah tobacco products including reducing humectants and sugar additives, which are precursors of acrolein under certain pyrolysis conditions. We suggest posting health warning signs for indoor smoking in hookah lounges, and encouraging voluntary bans of smoking hookah tobacco in private homes.

Implications

Our study is the first to quantify the increase in acrolein exposure in hookah smokers and non-smokers exposed to exclusively hookah tobacco SHS at hookah social events in homes or hookah lounges. Our findings provide additional support for regulating hookah tobacco product content, protecting non-smokers' health by posting health warning signs for indoor smoking in hookah lounges, and encouraging home bans on hookah tobacco smoking to safeguard vulnerable residents.

Knowledge, attitudes, beliefs and patterns of waterpipe use among Jordanian adults who exclusively smoke waterpipes

BACKGROUND

Widespread waterpipe smoking (WPS) is reported worldwide. Although remarkable numbers of waterpipe smokers do not smoke cigarettes, very few studies have explored the phenomenon of WPS in people who smoke water pipes exclusively. The aim of this study was to assess levels of knowledge, attitudes, beliefs and patterns of WPS among Jordanian waterpipe-only smokers.

METHODS

A cross-sectional descriptive design was used; with 247 participants who were recruited through convenience sampling from 23 cafés offering waterpipes. An interview and self-reported questionnaire was used to collect data.

RESULTS

The average age for starting WPS was 19.4 ± 5.6 years, of whom 71% started as teenagers. Participants like WPS because they like its flavor and social environment (46.3% and 29.5% respectively). The majority of participants reported that they smoked a waterpipe for the first time with their friends (66.8%), they usually smoke in the company of others (63.2%), and believe that quitting cigarettes smoking is harder than quitting WPS (61.6%). More than half (56.7%) of participants have extremely poor knowledge about the health effects of WPS. Participants who had smoked cigarettes in the past, were more knowledgeable than those who had never smoked cigarettes. The majority of participants, and specifically women, have high positive feelings and emotions (attitude) toward WPS, and 88.3% of them reported that it is a socially acceptable behavior.

CONCLUSIONS

Waterpipe smoking participants started WPS at an early age, and are attracted to the social environment that accompanies WPS. Participants have high positive attitude about WPS however they lack knowledge about harmful health effects of WPS.

A Man in His 20s With Diffuse Lung Opacities and Acute Respiratory Failure After Hookah Smoking

A man in his 20s with no medical history presented with 2 days of progressively worsening shortness of breath accompanied by subjective fevers, chills, body aches, decreased appetite, night sweats, and cough producing nonbloody sputum. He denied childhood lung diseases, allergies, or a family history of lung disease. He did not smoke cigarettes but had smoked hookah in Saudi Arabia before moving to the United States 1 month before presentation and had restarted 2 days before the start of symptoms. He denied travel outside of the northeastern United States. He did not take medications, use illicit drugs, or engage in high-risk behavior.

A European Respiratory Society technical standard: exhaled biomarkers in lung disease

Breath tests cover the fraction of nitric oxide in expired gas (F_eNO), volatile organic compounds (VOCs), variables in exhaled breath condensate (EBC) and other measurements. For EBC and for F_eNO, official recommendations for standardised procedures are more than 10 years old and there is none for exhaled VOCs and particles. The aim of this document is to provide technical standards and recommendations for sample collection and analytic approaches and to highlight future research priorities in the field. For EBC and F_eNO, new developments and advances in technology have been evaluated in the current document. This report is not intended to provide clinical guidance on disease diagnosis and management.Clinicians and researchers with expertise in exhaled biomarkers were invited to participate. Published studies regarding methodology of breath tests were selected, discussed and evaluated in a consensus-based manner by the Task Force members.Recommendations for standardisation of sampling, analysing and reporting of data and suggestions for research to cover gaps in the evidence have been created and summarised.Application of breath biomarker measurement in a standardised manner will provide comparable results, thereby facilitating the potential use of these biomarkers in clinical practice.

Health Effects of Waterpipe Tobacco Use: Getting the Public Health Message Just Right

Many public health messages benchmark the harms of waterpipe tobacco against those of cigarettes, usually using numerical magnitudes of risk. This approach, although well intentioned, could be perceived as alarmist, damaging scientific credibility, and giving an unintended impression that one tobacco product is less harmful than the other. This commentary makes clear the harm waterpipe tobacco smoking poses to public health by describing its mechanism of use, consumption uptake, toxicologic profile, and documented health outcomes, as well as challenge existing thinking that toxicologic assessments are the most appropriate way to frame waterpipe tobacco health promotion messages. How can we describe the health effects of waterpipe tobacco without undermining its toxicity nor falling into the temptation of alarmist messaging? Several recommendations are provided.

Combined Effects of in Utero and Adolescent Tobacco Smoke Exposure on Lung Function in C57Bl/6J Mice

BACKGROUND

Fetal determinants of airway function, such as in utero exposure to maternal cigarette smoke (CS), may create a predisposition to adult airflow obstruction and chronic obstructive pulmonary disease (COPD) in adulthood. It has been suggested that active smoking in adolescence and preexisting airflow obstruction have synergistic deleterious effects.

OBJECTIVE

We used a mouse model to investigate whether there is a synergistic effect of exposure to CS in utero and during adolescence on lung function.

METHODS

Female C57Bl/6J mice were exposed to CS or to filtered room air during pregnancy. Exposure to CS began 2 weeks before mating and continued until delivery. After birth, the pups were not exposed to CS until day 21 (D21). Between D21 and D49, corresponding to "adolescence," litters were randomized for an additional 4 weeks of exposure to CS. Lung morphometry, lung mechanics, and the expression of genes involved in senescence were evaluated in different subsets of mice on D21 and D49.

RESULTS

In utero exposure to CS induced significant lung function impairment by D21. CS exposure between D21 and D49 induced significant functional impairment only in mice exposed to CS prenatally. On D49, no difference was observed between subgroups in terms of lung p53, p16, p21, and Bax mRNA levels.

CONCLUSIONS

Our findings suggest that prenatal and adolescent CS exposure have a synergistic effect on lung function in mice. The combined effect did not appear to be a consequence of early pulmonary senescence. Citation: Drummond D, Baravalle-Einaudi M, Lezmi G, Vibhushan S, Franco-Montoya ML, Hadchouel A, Boczkowski J, Delacourt C. 2017. Combined effects of in utero and adolescent tobacco smoke exposure on lung function in C57Bl/6J mice. Environ Health Perspect 125:392-399; http://dx.doi.org/10.1289/EHP54.

Assessing the Effect of Waterpipe Smoking on Cancer Outcome - a Systematic Review of Current Evidence

Background: Waterpipe smoking (WPS) is widely believed to be a safe and hazard-free tobacco habit. However, a number of studies have indicated that exposure to several toxicants and carcinogens through WPS is strongly related to serious health hazards. The current paper presents a narrative review on the effects of WPS on cancer outcome. Methods: The addressed focused question was “Is there an association between waterpipe smoking and cancer outcome?” PubMed, Medline, EMBASE, ISI Web of Science and the Cochrane databases were searched until June 2015 using the key words “Waterpipe”, “Hookah”, “Narghileh”, “Shisha”, “Hubbly Bubbly” “cancer” in various combinations. Letters to the Editor, review articles, case-reports and unpublished articles were excluded. Results: A total of 16 studies were included: six on lung cancer, three on oesophageal cancer, two on gastric cancer, two on bladder cancer, and one each on nasopharyngeal, pancreatic and prostate cancers. Our search did not yield any study that evaluated the risk of oral cancer in WPS users. The available evidence showed a significant association of WPS with lung cancer (UOR 6.0, 95% CI 1.78–20.26); however, no association was observed with bladder, nasopharyngeal, pancreatic and prostate cancers. Gastric (OR 3.4, 95% CI 1.7-7.1) and oesophageal cancers (OR 1.85, 95% CI 1.41-2.44) were observed to have weak associations with WPS. Conclusion: Regardless of the limitations, there is sufficient evidence to suggest associations of WPS with cancer, particularly in the lung. Future well-designed studies are required to identify and quantify with confidence all the health effects of this form of smoking.

The effect of habitual waterpipe tobacco smoking on pulmonary function and exercise capacity in young healthy males: A pilot study

BACKGROUND

Evidence regarding the health effects of habitual waterpipe smoking is limited, particularly in young smokers. Respiratory health and cardiopulmonary exercise tests were compared in young male habitual waterpipe smokers (WPS) versus non-smokers.

METHODS

69 WPS (≥3 times/week for three years) and 69 non-smokers were studied. Respiratory health was assessed through the American Thoracic Society and the Division of Lung Diseases (ATS-DLD-78) adult questionnaire. Pulmonary function and cardiopulmonary exercise tests were performed. Self-reported respiratory symptoms, forced expiratory volume in first second (FEV1), forced vital capacity (FVC), FEV1/FVC ratio, forced expiratory flow between 25 and 75% of FVC (FEF25-75%), peak expiratory flow (PEF), exercise time, peak end-tidal CO2 tension (PetCO2), subject-reported leg fatigue and dyspnea; peak O2 uptake (VO2 max), and end-expiratory lung volume (EELV) change from baseline (at peak exercise) were measured.

RESULTS

WPS were more likely than non-smokers to report respiratory symptoms. WPS also demonstrated: shorter exercise time; lower peak VO2; higher perceived dyspnea at mid-exercise; lower values of the following: FEV1, FVC, PEF, and EELV change.

CONCLUSION

Habitual waterpipe tobacco smoking in young seemingly healthy individuals is associated with a greater burden of respiratory symptoms and impaired exercise capacity.

Waterpipe tobacco smoking and its human health impacts

Waterpipe tobacco smoking (WTS, also known as hookah, shisha, narghile, and many other names) involves passing tobacco smoke through water prior to inhalation by the consumer. As the number of waterpipe smokers is rising rapidly, there is growing concern over the use of WTS, particularly as there has been a widely held misconception that WTS is free from health hazards. In reality, it is associated with a variety of adverse health outcomes on both a short- and long-term basis. Hence, it is desirable to develop advanced techniques for surveillance, intervention, and regulatory/policy frameworks specific to the production and use of waterpipe tobacco. This review is written to survey the types and extent of pollutants released from its use and their potential health risks. A review of the present regulation guidelines is also included.

Waterpipe smoking and risk of coronary artery disease

PURPOSE OF REVIEW

Smoking tobacco using a water pipe is becoming more prevalent globally, particularly amongst younger populations. In addition to its growing popularity, more evidence is emerging regarding associated harm, and several misconceptions exist concerning the likely adverse health effects of waterpipe smoking (WPS). It is timely, therefore, to examine the body of evidence linking WPS to coronary artery disease (CAD). Here, we review the direct evidence linking WPS to CAD and examine additional, indirect evidence of associated harm. We discuss the clinical and public health implications of the current evidence and provide suggestions for further research.

RECENT FINDINGS

A multicentre case-control study in Lebanon has recently demonstrated an association between WPS and CAD. There are few prior studies making this direct link. However, a large body of evidence has emerged showing close similarities between WPS and cigarette smoking with regard to the toxicity of smoke and acute inflammatory and haemodynamic effects following exposure to it.

SUMMARY

There are consistent similarities between WPS and cigarette smoking in regard to association with CAD, the nature of the smoke produced, and the acute haemodynamic effects and inflammatory responses that follow exposure. These findings justify both public health and clinical interventions to reduce WPS. Further studies are warranted to confirm a causal association between WPS and CAD.

Immediate effects of cigar smoking on respiratory mechanics and exhaled biomarkers; differences between young smokers with mild asthma and otherwise healthy young smokers

Background

We aimed to investigate the immediate respiratory effects of cigar smoking(CS), among young smokers with and without mild asthma.

Materials and methods

Forty-seven young smokers (18–31years old, 29 males, average pack-years = 3.6 ± 2.8) were enrolled. Twenty-two were mild asthmatics(MA-subgroup) and the remaining 25 were otherwise healthy smokers(HS-subgroup). Exhaled carbon monoxide(eCO), multi-frequency respiratory system impedance(Z), resistance(R), reactance(X), frequency-dependence of resistance(fdr = R5Hz - R20Hz), resonant frequency(f_res), reactance area(AX) and exhaled nitric oxide(FENO) were measured at the aforementioned sequence, before and immediately after 30 min of CS, or equal session in the smoking area while using a sham cigar(control group). Chi-square, student’s t-tests, mixed linear models and Pearson correlation tests were used for the statistical analysis; level of significance was defined as p < 0.05.

Results

Immediately after CS, Z5Hz, R5Hz, R10Hz, R20Hz and eCO increased significantly in both subgroups(MA and HS). A greater increase was found for R20 in HS-subgroup. Fdr, f_res and AX increased in MA, while decreased in HS. On the contrary, X10 decreased in MA and increased in HS, while X20 showed a greater decrease in MA. Changes in fdr, f_res and AX were significantly correlated in both subgroups. No significant FENO alterations were detected in both subgroups.

Conclusion

CS has immediate effects on pulmonary function. Mild asthma predisposes to higher increase of peripheral resistance(increased fdr). In otherwise healthy smokers, central resistance(R20Hz) is more affected. FENO levels are not significantly affected by CS.

A Systematic Review of Effects of Waterpipe Smoking on Cardiovascular and Respiratory Health Outcomes

BACKGROUND

Waterpipe smoking (WPS) is a social custom common in many Middle Eastern, North African, and Asian countries and has become increasingly popular in the US, especially among youth; however, WPS smoking may be increasing in the US adult population as well. There is a common belief among waterpipe (WP) smokers that WPS is less harmful than smoking cigarettes. Thus, this review aims to systematically explore the literature on the effects of WP tobacco smoking with a particular focus on cardiovascular and respiratory health outcomes as well as on oxidative stress, immunity, and cell cycle interference health outcomes.

METHODOLOGY

We conducted a systematic review, guided by the criteria of The Preferred Reporting Items for Systematic Reviews and Meta-Analyses, using the following online databases MEDLINE, CINAHL, ScienceDirect, PMC, and Cochrane Library. Results were summarized qualitatively.

RESULTS

Forty studies met the inclusion criteria established for this review. Based on the existing evidence, several cardiovascular and respiratory physiologic health indicators and conditions have been shown to be negatively affected by WPS. In addition to the effects of nicotine and chemical toxicant exposures, WPS was significantly associated with an increase in heart rate, blood pressure, and lower pulmonary function test results, as well as a number of health conditions such as lung cancer, alterations in oxidative stress, immunity, and cell cycle interference.

CONCLUSION

The current literature provides evidence that WPS is associated with a number of negative health indicators and outcomes. There is need for more research related to WPS and its effects on health so that appropriate campaigns and prevention interventions can be implemented to control the epidemic increase of WPS in the US.

Waterpipe tobacco smoking: A new smoking epidemic among the young?

Waterpipe (hookah, narghile) tobacco smoking (WTS) is becoming prevalent worldwide and is one of the most popular forms of tobacco use among youth. WTS prevalence has increased dramatically among youth in the United States within the past decade. Misperceived as less harmful than cigarette smoking, WTS is associated with many of the same chronic health effects such as lung cancer, chronic obstructive pulmonary disease, cardiovascular disease, bronchitis, and asthma. Much of this risk is due to the fact that a single WTS session exposes users to large volumes of smoke that contain toxic chemicals such as carbon monoxide, cancer-causing polycyclic aromatic hydrocarbons, and volatile aldehydes. Unlike cigarette smoking, WTS poses unique risks of acute negative health outcomes including carbon monoxide poisoning and the spread of communicable diseases such as herpes and tuberculosis. Because waterpipe tobacco smoke contains the addictive chemical nicotine, youth who smoke tobacco from a waterpipe may be at risk for dependence. As a result, many youth may initiate WTS and continue to use despite negative health effects. Considering many of the potential negative health effects associated with WTS affect the pulmonary system, pulmonologists and primary care providers may treat patients who are waterpipe tobacco smokers and should be aware of the risk associated with WTS. The purpose of this review is to describe a waterpipe, the prevalence and correlates of WTS, the toxicants found in waterpipe tobacco smoke, the health effects of WTS, and implications for pulmonologists and other clinicians.

Design and Validation of a Research-Grade Waterpipe Equipped With Puff Topography Analyzer

INTRODUCTION

Worldwide, commercially available waterpipes vary widely in design and durability, including differences in fabrication materials, degree of leak-tight fit, and flow path diameter. Little is known about how the components of the waterpipe may influence puffing behavior and user's exposure to toxins. To systematically evaluate exposure, it is necessary to use a standardized research-grade waterpipe (RWP) when conducting clinical and laboratory-based trials.

METHODS

We developed a RWP that is configured with an in-line topography system which allows real-time measurement and recording of the smoke volume drawn through the RWP. The RWP was calibrated across the flow rate range expected for waterpipe tobacco smoking and the calibration was verified for known puff volumes using a smoking machine. Operation of the RWP was qualified in a cohort of experienced waterpipe smokers, each smoker using the RWP ad libitum in a laboratory setting while smoker topography and subjective effects data were collected.

RESULTS

RWP machine smoking was highly reproducible and yielded puff volumes that agreed well with true values. User acceptance was comparable, and puffing behavior was similar in pattern, with more frequent puffing in the beginning of the session, but significantly different in intensity from that used to estimate the majority of toxicant exposure reported in the literature.

CONCLUSIONS

The RWP operates with known precision and accuracy and is well accepted by experienced smokers. This tool can be used to determine the extent to which puffing behaviors are affected by the waterpipe design, components, and/or accessories, tobacco nicotine content, sweet flavorings and/or additives known to increase addictiveness.

IMPLICATIONS

This study describes a standardized RWP, equipped with a puffing topography analyzer, which can operate with known precision and accuracy, and is well-accepted by experienced smokers in terms of satisfaction and reward. The RWP is an important tool for determining if puffing behaviors, and thus estimated toxin exposures, are affected by the waterpipe design, components, and/or accessories, tobacco nicotine content, sweet flavorings, and/or additives that are known to increase addictiveness.

Exhaled Breath Condensate: Technical and Diagnostic Aspects

Purpose. The aim of this study was to evaluate the 30-year progress of research on exhaled breath condensate in a disease-based approach. Methods. We searched PubMed/Medline, ScienceDirect, and Google Scholar using the following keywords: exhaled breath condensate (EBC), biomarkers, pH, asthma, gastroesophageal reflux (GERD), smoking, COPD, lung cancer, NSCLC, mechanical ventilation, cystic fibrosis, pulmonary arterial hypertension (PAH), idiopathic pulmonary fibrosis, interstitial lung diseases, obstructive sleep apnea (OSA), and drugs. Results. We found 12600 related articles in total in Google Scholar, 1807 in ScienceDirect, and 1081 in PubMed/Medline, published from 1980 to October 2014. 228 original investigation and review articles were eligible. Conclusions. There is rapidly increasing number of innovative articles, covering all the areas of modern respiratory medicine and expanding EBC potential clinical applications to other fields of internal medicine. However, the majority of published papers represent the results of small-scale studies and thus current knowledge must be further evaluated in large cohorts. In regard to the potential clinical use of EBC-analysis, several limitations must be pointed out, including poor reproducibility of biomarkers and absence of large surveys towards determination of reference-normal values. In conclusion, contemporary EBC-analysis is an intriguing achievement, but still in early stage when it comes to its application in clinical practice.

Early pulmonary events of nose-only water pipe (shisha) smoking exposure in mice

Water pipe smoking (WPS) is increasing in popularity and prevalence worldwide. Convincing data suggest that the toxicants in WPS are similar to that of cigarette smoke. However, the underlying pathophysiologic mechanisms related to the early pulmonary events of WPS exposure are not understood. Here, we evaluated the early pulmonary events of nose-only exposure to mainstream WPS generated by commercially available honey flavored "moasel" tobacco. BALB/c mice were exposed to WPS 30 min/day for 5 days. Control mice were exposed using the same protocol to atmospheric air only. We measured airway resistance using forced oscillation technique, and pulmonary inflammation was evaluated histopathologically and by biochemical analysis of bronchoalveolar lavage (BAL) fluid and lung tissue. Lung oxidative stress was evaluated biochemically by measuring the level of reactive oxygen species (ROS), lipid peroxidation (LPO), reduced glutathione (GSH), catalase, and superoxide dismutase (SOD). Mice exposed to WPS showed a significant increase in the number of neutrophils (P < 0.05) and lymphocytes (P < 0.001). Moreover, total protein (P < 0.05), lactate dehydrogenase (P < 0.005), and endothelin (P < 0.05) levels were augmented in bronchoalveolar lavage fluid. Tumor necrosis factor α (P < 0.005) and interleukin 6 (P < 0.05) concentrations were significantly increased in lung following the exposure to WPS. Both ROS (P < 0.05) and LPO (P < 0.005) in lung tissue were significantly increased, whereas the level and activity of antioxidants including GSH (P < 0.0001), catalase (P < 0.005), and SOD (P < 0.0001) were significantly decreased after WPS exposure, indicating the occurrence of oxidative stress. In contrast, airway resistance was not increased in WPS exposure. We conclude that subacute, nose-only exposure to WPS causes lung inflammation and oxidative stress without affecting pulmonary function suggesting that inflammation and oxidative stress are early markers of WPS exposure that precede airway dysfunction. Our data provide information on the initial steps involved in the respiratory effects of WPS, which constitute the underlying causal chain of reactions leading to the long-term effects of WPS.

Health effects associated with waterpipe smoking

OBJECTIVE

It is widely held that waterpipe smoking (WPS) is not associated with health hazards. However, several studies have documented the uptake of several toxicants and carcinogens during WPS that is strongly associated with harmful health effects. This paper reviews the literature on the health effects of WPS.

DATA SOURCES

Three databases-PubMed, MEDLINE and EMBASE-were searched until August 2014 for the acute and long-term health effects of WPS using the terms 'waterpipe' and its synonyms (hookah, shisha, goza, narghileh, arghileh and hubble-bubble) in various spellings.

STUDY SELECTION

We included original clinical studies, case reports and systematic reviews and focused on clinical human studies. ∼10% of the identified studies met the selection criteria.

DATA EXTRACTION

Data were abstracted by all three authors and summarised into tables. Abstracted data included study type, results and methodological limitations and were analysed jointly by all three authors.

DATA SYNTHESIS

WPS acutely leads to increased heart rate, blood pressure, impaired pulmonary function and carbon monoxide intoxication. Chronic bronchitis, emphysema and coronary artery disease are serious complications of long-term use. Lung, gastric and oesophageal cancer are associated with WPS as well as periodontal disease, obstetrical complications, osteoporosis and mental health problems.

CONCLUSIONS

Contrary to the widely held misconception, WPS is associated with a variety of adverse short-term and long-term health effects that should reinforce the need for stronger regulation. In addition, this review highlights the limitations of the published work, which is mostly cross-sectional or retrospective. Prospective studies should be undertaken to assess the full spectrum of health effects of WPS, particularly in view of its growing popularity and attractiveness to youth.