The acute effects of waterpipe smoking on lung function and exercise capacity in a pilot study of healthy participants

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.

The adverse health effects of waterpipe smoking in adolescents and young adults: A narrative review

Waterpipe (WP) smoking has rapidly grown in popularity in the United States and other Western countries with the fastest uptake among younger individuals. This growth has been encouraged by the misperception that WP smoke is harmless or less harmful than cigarette smoke. To better understand how WP affects the health of young people, we conducted a narrative review of the literature focusing on the adverse health effects of WP smoking in adolescents and younger adults. We searched scientific literature databases including PubMed, MEDLINE, EMBASE, and ISI Web and selected papers that met the inclusion criteria. Sixty-three papers met the inclusion criteria and were selected for review. Data were abstracted from the selected papers into a standardized table. The evidence demonstrates that WP smoking can cause acute lung infection and injury, and carbon monoxide (CO) poisoning, in adolescents and young adults. It is also associated with adverse subclinical effects in this sub-population, including oral and systemic genotoxicity, lung function decline, and the alteration of vascular and hemodynamic functions. Limited evidence that is available indicates associations with psychological and neurological effects and asthma. No identified publications examined the association between WP use and type 2 diabetes, a condition that is associated with cigarette smoking among young people. WP smoking by younger individuals can result in their hospitalization due to systemic CO poisoning and acute lung disease, and induce subclinical adverse effects in the oral cavity, pulmonary system, and in circulation, that are involved in the pathogenesis of local and systemic chronic diseases.

Characteristics of flavored and non-flavored waterpipe tobacco users: a real-world setting study

We aimed to compare sociodemographic characteristics, smoking patterns, beliefs and perceptions, nicotine dependence, and psychological indicators between flavored waterpipe (WP) tobacco (FWT) and non-flavored WP tobacco (non-FWT) smokers in Iran. A cross-sectional study was conducted in 94 WP-serving venues surrounding Tehran and Ardabil metropolitans in Iran. Convenience sampling was applied to select 900 current WP smokers [508 (56%) FWT-only and 392 (44%) non-FWT-only smokers] aged 18 years and older. Multivariable logistic regression was used to examine the independent characteristics of FWT and non-FWT smokers. Compared to non-FWT smokers, FWT smokers were younger (adjusted odds ratio [AOR]=0.88, 95% confidence interval [CI]: 0.87-0.90) and more likely to have ≥ 1 sibling who smoked WP (AOR=1.54, 95% CI: 1.06-2.24), share WP with others (AOR=2.52, 95% CI: 1.68-3.77), report current cigarette smoking (AOR=2.05, 95% CI: 1.23-3.42), and report confidence in quitting at any time (AOR=3.64, 95% CI: 2.45-5.39). FWT smokers were less likely to have seen (AOR=0.40, 95% CI: 0.27-0.60) or read (AOR=0.44, 95% CI: 0.24-0.80) warning messages on WP tobacco packages relative to non-FTW smokers. The most common self-reported reason for smoking WP was entertainment for both groups, followed by stress relief for non-FWT smokers and the escape from loneliness for FWT smokers. FWT-only smokers differ from non-FWT-only smokers in several aspects including being younger, having more positive beliefs and perceptions regarding WP use, and having higher cigarette smoking prevalence. These findings will help in developing more effective and targeted policies and cessation interventions for WP smokers according to flavor type they use, especially in the Middle East.

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.

Waterpipe use and associated consumer characteristics in the German population: Data from a national representative survey (DEBRA study)

BACKGROUND

Waterpipes (WP) have a long tradition in certain regions of the world, and their use has been increasing worldwide. Current data on the use of WP in different subgroups of the German population are missing.

OBJECTIVE

To estimate the current prevalence of WP use and associated socio-demographic characteristics, tobacco smoking status and e-cigarette usage behaviour in the German population aged ≥14 years; to describe the frequency of use and starting age in current WP users.

METHODS

We analysed data from waves 13-18 (June/July 2018-April/May 2019; N = 12,220) of the German Study on Tobacco Use (DEBRA) - a representative, computer-assisted national household survey. Associations of socio-demographic characteristics, tobacco smoking status and e-cigarette usage behaviour were assessed with multivariable logistic regression models.

RESULTS

A total of 1.8% (n = 217) (95% confidence interval (CI) = 1.5%-2.0%) of the population were current WP users, 13% (n = 1618) (95% CI = 12.3%-13.5%) were ever users. Adjusted multivariable logistic models showed that people with migration background, male sex, younger age, and those who were smokers or used e-cigarettes, were more likely to use a WP. Among current WP users, 15.2% (n = 33) (95% CI = 10.7%-20.7%) had started to use WP at the age of 26 or older, and 23.0% (n = 50) (95%CI = 17.6%-29.2%) had used WP at least once a week or almost daily in the last month.

CONCLUSIONS

In Germany, the use of WP is popular and most strongly associated with migration background and use of tobacco and e-cigarettes. These aspects should be considered when designing future target group-specific prevention strategies.

Oxidative Stress and Inflammation Induced by Waterpipe Tobacco Smoking Despite Possible Protective Effects of Exercise Training: A Review of the Literature

The prevalence of waterpipe tobacco smoking (WTS), which is also known as ghalyan, shisha or hookah, is increasing rapidly around the world, especially among youth. Growing interest in this form of tobacco smoking can be traced, in part, to the use of flavored tobacco products, social acceptability as a safer option than cigarettes, and its consideration as a relaxation method or entertainment. However, there is a well-established association between WTS and oxidative stress that causes irreversible chronic pathological conditions such as cardiovascular and respiratory problems, as well as different types of cancers, and thus increases the risk of mortality. Clearly, induction of inflammation status through increased reactive oxygen species (ROS), which in turn leads to oxidative stress and harm to lipids, DNA, and proteins, is the most plausible mechanism to explain the potential harmful effects of WTS. Unlike WTS, well-designed exercise training programs increase ROS to the extent that it is beneficial to the body. In this study, we aimed to review available evidence on the impact of exercise training on oxidative stress and inflammation status. We also summarize the effect of acute and chronic WTS on different exercise capacities.

Microbial contamination and infection risks of narghile besides hazards of tobacco

OBJECTIVE

Water-pipe smoking has become a serious public health threat worldwide. In order to raise awareness of adverse effects and transmission of bacteria via water-pipe smoking, we aimed to identify the bacteria and their antimicrobial resistance profiles that colonize different parts of waterpipes.

METHODS

We examined totally 182 water pipes from 7 lounges (in Turkey) used in public places and we collected 728 culture samples in total by microbiological methods. We used disposable sterile swabs to sample the inside and outside of the mouthpiece, and the handling piece and sterile injectors were used to collect 5 mL of water from the water pipe bowl.

RESULTS

There was a significant (p < 0.05) difference in microbial contamination (growth/presence of bacteria and fungi) among the parts of the water pipes sampled. There was a significant (p < 0.05) difference in the number of bacteria growing (microbial load) among the parts of the water pipes. Only one narghile lounge out of seven, which had 13 water pipes, had a hygiene procedure. The water jars are often contaminated with Gram-negative bacteria.

CONCLUSION

Water pipes, especially the interior and outer part of the mouthpieces and the handle, are colonized by microbes and pose a risk of infection. Procedures for water pipe hygiene should be developed, periods should be defined, and the owners and employees of establishments and water-pipe smokers should be educated in this regard. Water-pipe smoking is a threat to public health and should be regulated by the state.

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.

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.

Short-Term Exposure to Waterpipe/Hookah Smoke Triggers a Hyperactive Platelet Activation State and Increases the Risk of Thrombogenesis

OBJECTIVE

Cardiovascular disease is a major public health problem. Among cardiovascular disease's risk factors, tobacco smoking is considered the single most preventable cause of death, with thrombosis being the main mechanism of cardiovascular disease mortality in smokers. While tobacco smoking has been on the decline, the use of waterpipes/hookah has been rising, mainly due to the perception that they are less harmful than regular cigarettes. Strikingly, there are few studies on the negative effects of waterpipes on the cardiovascular system, and none regarding their direct contribution to thrombus formation. Approach and Results: We used a waterpipe whole-body exposure protocol that mimics real-life human exposure scenarios and investigated its effects, relative to clean air, on platelet function, hemostasis, and thrombogenesis. We found that waterpipe smoke (WPS)-exposed mice exhibited both shortened thrombus occlusion and bleeding times. Further, our results show that platelets from WPS-exposed mice are hyperactive, with enhanced agonist-induced aggregation, dense and α-granule secretion, αIIbβ3 integrin activation, phosphatidylserine expression, and platelet spreading, when compared with clean air-exposed platelets. Finally, at the molecular level, it was found that Akt (protein kinase B) and ERK (extracellular signal-regulated kinases) phosphorylation are enhanced in the WPS and in nicotine-treated platelets.

CONCLUSIONS

Our findings demonstrate that WPS exposure directly modulates hemostasis and increases the risk of thrombosis and that this is mediated, in part, via a state of platelet hyperactivity. The negative health impact of WPS/hookah, therefore, should not be underestimated. Moreover, this study should also help in raising public awareness of the toxic effects of waterpipe/hookah.

The effects of hookah/waterpipe smoking on general health and the cardiovascular system

Hookah or waterpipe smoking or use is an emerging trend in the US population, especially among the youth. The misperception of hookah being less harmful than cigarettes and the availability of different but "appealing" flavors are considered among the main reasons for this trend. Hookah users however are exposed to many of the same toxic compounds/by-products as cigarette users, but at dramatically higher levels, which might lead to more severe negative health effects. In fact, hookah users are at risks of infections, cancers, lung disease, and other medical conditions. Moreover, because of the overlapping toxicant/chemical profile to conventional cigarettes, hookah smoke effects on the cardiovascular system are thought to be comparable to those of conventional cigarettes. A major source of tobacco addiction is nicotine, whose levels in hookah are extremely variable as they depend on the type of tobacco used. Taken together, in this review of literature, we will provide insights on the negative health effects of hookah in general, with a focus on what is known regarding its impact on the cardiovascular system.

Respiratory health and quality of life in young exclusive, habitual smokers - a comparison of waterpipe smokers, cigarette smokers and non-smokers

Purpose

Waterpipe (WP) use has become a global trend in young populations. However, there are few well-controlled studies focusing specifically on the chronic effects of exclusive WP use on young adults’ respiratory health. We sought to compare in young adults the burden of respiratory symptoms in regular WP smokers (WPS) relative to regular cigarette smokers (CS, positive controls) and non-smokers (negative controls); and to evaluate differences in health-related quality of life between the three groups.

Method

We implemented a cross-sectional survey in college campuses across four countries (Egypt, Jordan, Morocco and Oman). Purposive sampling was employed to identify habitual (regular) healthy WPS (smoked 3 or more WP per week for 3 or more years); CS (smoked 5 or more cigarettes daily for 3 or more years); and non-smokers. Respiratory symptoms were assessed using the European Community Respiratory Health Survey and the American Thoracic Society and the Division of Lung Diseases Questionnaire. Health-related quality of life was measured using the Short-Form 12. Demographic, environmental and lifestyle factors also were measured.

Result

The analytic sample included 135 WPS, 303 CS, and 300 non-smokers. Either tobacco group had significantly greater proportions of males than the non-smoker group. A significantly lower proportion of non-smokers (than either tobacco group) was overweight or obese. Average numbers of reported respiratory symptoms were 5.1, 5.8, and 2.9 in WPS, CS, and non-smokers, respectively. In multivariable regressions controlling for environmental exposures, body mass index, and physical activity, WPS and CS exhibited significantly higher rates of respiratory symptoms than non-smokers (1.6 times greater and 1.9 times greater rate of respiratory symptoms than non-smokers, respectively). Non-smokers reported significantly higher scores for general health relative to either WPS or CS.

Conclusion

Relative to their young non-smoking counterparts, young habitual WPS exhibit a significant burden of respiratory symptoms that is comparable to that observed with CS. Young WPS (and CS), despite their age, may be well on their way to developing respiratory disease.

Prevalence and Perception of Shisha Smoking among University Students: A Cross-sectional Study

Aims and Objectives:

Understanding perceptions and factors behind the rise in the prevalence of shisha smoking is important for the development of prevention strategies and policies. The aim of this descriptive study was to assess the prevalence and perception of shisha smoking among university students.

Materials and Methods:

The anonymous, self-structured 12-item questionnaire was administered to 450 male university students, with an overall response rate of 82.44% (n = 371). Prevalence, knowledge, and other associated factors regarding shisha smoking were compared between dental and other specialty students using SPSS software for descriptive statistical analysis.

Results:

Among 371 university students, 40.43% (n = 150) were nonsmokers, 32.88% (n = 122) were shisha smokers, 12.94% (n = 48) were cigarette smokers, and 13.75% (n = 51) smoked both shisha and cigarette. The overall prevalence of shisha smoking (46.63%, n = 173) was higher than that of cigarette smoking (26.68%, n = 99). The percentage of those knowledgeable about the ill effects of shisha smoking was 44.2% with lesser knowledge among shisha smokers than cigarette smokers. There was no statistically significant difference in the mean total knowledge score between dental (5.65 ± 2.08) and other specialty (5.21 ± 2.3) students.

Conclusions:

A high prevalence of shisha use among university students is reported in this study as well as a general lack of understanding of the dangers involved with this behavior. Study authors recommend the development of policies targeted at preventing further rise in the prevalence of shisha smoking through the implementation of preventive strategies such as incorporating this topic into the school syllabus and encouraging research on shisha smoking.

Cigarette Smoking Blunts Exercise-Induced Heart Rate Response among Young Adult Male Smokers

This study aimed to examine the exercise-induced heart rate response (HRR) and heart rate variability (HRV) in subjects caused by inhaling smoke from tobacco cigarettes (TC) and aerosolized vapor from electronic nicotine dispensing systems (ENDS) (commonly referred to as e-cigarettes (EC)). A randomized crossover study recruited 24 young adult male smokers with an average age of 23 years and with a smoking habit of at least two years. Heart rate response was recorded after a maximal multistage shuttle 20 m run test (MMST) under three different levels of nicotine: Control 0 mg nicotine of EC (C), 3 mg nicotine of EC (3EC), and 3 mg nicotine of TC (3TC). HRV was evaluated based on the beat-to-beat time interval during the running test. The results showed no statistically significant differences in the run time to exhaustion under the three conditions (C: 398 ± 151 s; 3EC: 399 ± 160 s; 3TC: 381 ± 150 s). Exercise-induced HRR was significantly attenuated under the TC condition (p < 0.05). Intriguingly, the HRV standard deviation of normal-to-normal intervals (SDNN) during exercise significantly increased under 3EC and 3TC. The results showed that a significant acute autonomic cardiac modulation during exercise is induced by an acute episode of EC and TC smoking.

Epidemiology and Adverse Consequences of Hookah/Waterpipe Use: A Systematic Review

Hookah smoking is becoming a popular trend globally. Waterpipe smoking is the second most prevalent form of alternate tobacco products. The rapid increase in hookah use is because of the misconception prevalent in society that hookah smoking is less harmful than cigarette smoking. Smoking ban policies had given impetus of switching from cigarette smoking to alternate tobacco products like waterpipe. Hookah users regard hookah to be more socially acceptable, less stigmatizing with flavors and to alleviate cigarette craving symptoms. Newer basic science research on animal models and human cells has shown consistently mutagenic, oxidative, and inflammatory changes that could cause possible health effects of premalignant oral lesion and chronic diseases like atherosclerosis and chronic obstructive pulmonary disease. Studies on the chemistry of waterpipe smoke had shown alarming results with the smoke containing seven carcinogens, 39 central nervous system depressants, and 31 respiratory irritants. Enormous data exist showing waterpipe smoking causing various health effects. Hookah smoking effects on cardiovascular disease is additive with hookah containing a significant amount of nicotine, tar, and heavy metals causing both acute and chronic effects on the cardiovascular system. These effects include increased heart rate, blood pressure, prevalence of coronary heart disease, heart failure, ST-segment elevation myocardial ischemia, recurrent ischemia, and worse outcomes including mortality related to these diseases. The objectives of the review are to assess the factor associated with the increasing use of hookah, its health effects, options for hookah smoking cessation, and public health policy initiatives to mitigate waterpipe use.

Water Pipe (shisha) Use and Legislation Awareness Against Shisha Smoking Among Medical Students: A study from Karachi, Pakistan

The aim of the study was to determine the prevalence of shisha smoking; its associated factors and awareness among medical students of Karachi, Pakistan following the imposition of nationwide shisha ban. A cross sectional study was conducted among medical students of two medical universities, namely Sindh Medical College and Aga Khan University Karachi, Pakistan from October till December 2014. A total of 422 participants were included. Data was collected via a self-administered questionnaire. The mean age was 21 ± 1.6 years and 229 (54.26 %) were females. Shisha smoking was found to be relatively common among medical students; the prevalence being 21.5 % out of which 73.62 % were males and belonged to a private medical college p value < 0.001. Majority of those who smoked shisha were aware that it contains tobacco (59.34 %), it has no filtration system (42.85 %), it is harmful (91.20 %) and 47.25 % held the opinion that shisha was not any better than cigarettes. It was alarming that majority students were aware of its harmful effects. However, a significant lack of awareness of the legislation against shisha was found among students.

American pediatric society's 2017 John Howland award acceptance lecture: a tale of two toxicants: childhood exposure to lead and tobacco

This article summarizes the presentation of the 2017 Howland Award to Michael Weitzman, MD, at the Annual Pediatric Academic Society Meetings. It summarizes the remarkable advances in understanding the effects and pathways of exposure of the two most common and pernicious of our nation's child environmental exposures, namely lead and tobacco. It also summarizes the profound effect of the translation of these findings into prudent and effective clinical and public health policies such that exposure to both has dramatically decreased over the past 40 years due to the tenacious activities of pediatricians, other child-related professionals, government agencies at all levels, and the American Academy of Pediatrics. Research and clinical activities, although essential, were not sufficient to produce these successes, but required extensive mentoring to produce a generation of academic pediatricians capable of conducting the requisite research, and extensive advocacy by pediatricians and others to overcome the formidable inertia and outright opposition to efforts to protect our children from these exposures. Moreover, the article highlights that both of these environmental exposures have roots in social and environmental injustice and neither is solved, and that there is no safe level of exposure to either of these toxicants.

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.

Kinetics of Exhaled Carbon Monoxide After Water-pipe Smoking Indoors and Outdoors

BACKGROUND

Despite accumulating evidence about its adverse health effects, water-pipe tobacco smoking has become very popular among youth. The aim of this study was to compare smoke exposure and the kinetics of exhaled carbon monoxide (eCO) between water-pipe and cigarette smokers under different conditions.

METHODS

Using a cross-over study design, changes in eCO and urinary cotinine levels were measured in a cohort of 32 healthy university students after sessions of water-pipe smoking indoors and outdoors. An indoor cigarette smoking session with equal amounts of tobacco was conducted for reference purposes. Both active and passive smokers participated in all sessions.

RESULTS

In indoor sessions, we found that among active participants, eCO levels were approximately 7.5-fold higher in water-pipe users than cigarette smokers. eCO levels remained significantly elevated even 10 h after discontinuing water-pipe smoking. Notably, eCO levels in passive water-pipe smokers were in the same range as in active cigarette smokers. Compared with indoor sessions, eCO levels in active water-pipe users were reduced in outdoor environments. Nonetheless, levels were still higher in these subjects than those in active cigarette smokers measured in indoor sessions. Urinary cotinine levels were comparable in active water-pipe and cigarette smokers.

CONCLUSIONS

Our results suggest that water-pipe smoking is associated with significantly higher toxicant exposure than cigarette smoking even in outdoor environments. Furthermore, even passive, indoor water-pipe smoke exposure may have significant health hazards compared with those of active cigarette 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.

Nano-based rescue of dysfunctional autophagy in chronic obstructive lung diseases

INTRODUCTION

ΔF508-CFTR (cystic fibrosis transmembrane conductance regulator) is a common CF-mutation that is known to induce oxidative-inflammatory stress through activation of reactive oxygen species (ROS), which induces autophagy-impairment resulting in accumulation of CFTR in aggresome-bodies. Cysteamine, the reduced form of cystamine, is a FDA-approved drug that has anti-oxidant, anti-bacterial, and mucolytic properties. This drug has been shown in a recent clinical trial to decrease lung inflammation and improve lung function in CF patients by potentially restoring autophagy and allowing CFTR to be trafficked to the cell membrane. Areas covered: The delivery of cysteamine to airway epithelia of chronic subjects prerequisite the need for a delivery system to allow rescue of dysfunctional autophagy. Expert opinion: We anticipate based on our ongoing studies that PLGA-PEG- or Dendrimer-mediated cysteamine delivery could allow sustained airway delivery over standard cysteamine tablets or delay release capsules that are currently used for systemic treatment. In addition, proposed nano-based autophagy induction strategy can also allow rescue of cigarette smoke (CS) induced acquired-CFTR dysfunction seen in chronic obstructive pulmonary disease (COPD)-emphysema subjects. The CS induced acquired-CFTR dysfunction involves CFTR-accumulation in aggresome-bodies that can be rescued by an autophagy-inducing antioxidant drug, cysteamine. Moreover, chronic CS-exposure generates ROS that induces overall protein-misfolding and aggregation of ubiquitinated-proteins as aggresome-bodies via autophagy-impairment that can be also be resolved by treatment with autophagy-inducing antioxidant drug, cysteamine.

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.

Secondhand hookah smoke: an occupational hazard for hookah bar employees

BACKGROUND

Despite the increasing popularity of hookah bars, there is a lack of research assessing the health effects of hookah smoke among employees. This study investigated indoor air quality in hookah bars and the health effects of secondhand hookah smoke on hookah bar workers.

METHODS

Air samples were collected during the work shift of 10 workers in hookah bars in New York City (NYC). Air measurements of fine particulate matter (PM_2.5), fine black carbon (BC_2.5), carbon monoxide (CO), and nicotine were collected during each work shift. Blood pressure and heart rate, markers of active smoking and secondhand smoke exposure (exhaled CO and saliva cotinine levels), and selected inflammatory cytokines in blood (ineterleukin (IL)-1b, IL-6, IL-8, interferon γ (IFN-γ), tumour necrosis factor (TNF-α)) were assessed in workers immediately prior to and immediately after their work shift.

RESULTS

The PM_2.5 (gravimetric) and BC_2.5 concentrations in indoor air varied greatly among the work shifts with mean levels of 363.8 µg/m³ and 2.2 µg/m³, respectively. The mean CO level was 12.9 ppm with a peak value of 22.5 ppm CO observed in one hookah bar. While heart rate was elevated by 6 bpm after occupational exposure, this change was not statistically significant. Levels of inflammatory cytokines in blood were all increased at postshift compared to preshift testing with IFN-Υ increasing from 0.85 (0.13) to 1.6 (0.25) (mean (standard error of the mean; SEM)) pg/mL (p<0.01). Exhaled CO levels were significantly elevated after the work shift with 2 of 10 workers having values >90 ppm exhaled CO.

CONCLUSIONS

These results demonstrate that hookah bars have elevated concentrations of indoor air pollutants that appear to cause adverse health effects in employees. These data indicate the need for further research and a marked need for better air quality monitoring and policies in such establishments to improve the indoor air quality for workers and patrons.

Immediate Effects of Smoking on Cardiorespiratory Responses During Dynamic Exercise: Arm Vs. Leg Ergometry

Purpose: This study compared the immediate effects of smoking on cardiorespiratory responses to dynamic arm and leg exercises.

Methods:This randomized crossover study recruited 14 college students. Each participant underwent two sets of arm-cranking (AC) and leg-cycling (LC) exercise tests. The testing sequences of the control trial (participants refrained from smoking for 8 h before testing) and the experimental trial (participants smoked two cigarettes immediately before testing) were randomly chosen. We observed immediate changes in pulmonary function and heart rate variability after smoking and before the exercise test. The participants then underwent graded exercise tests of their arms and legs until reaching exhaustion. We compared the peak work achieved and time to exhaustion during the exercise tests with various cardiorespiratory indices [i.e., heart rate, oxygen consumption (VO₂), minute ventilation (V_E)]. The differences between the smoking and control trials were calculated using paired t-tests. For the exercise test periods, VO₂, heart rate, and V_E values were calculated at every 10% increment of the maximal effort time. The main effects of the time and trial, as well as their trial-by-time (4 × 10) interaction effects on the outcome measures, were investigated using repeated measure ANOVA with trend analysis.

Results: 5 min after smoking, the participants exhibited reduced forced vital capacities and forced expiratory volumes in the first second (P < 0.05), in addition to elevated resting heart rates (P < 0.001). The high-frequency, low-frequency, and the total power of the heart rate variability were also reduced (P < 0.05) at rest. For the exercise test periods, smoking reduced the time to exhaustion (P = 0.005) and the ventilatory threshold (P < 0.05) in the LC tests, whereas no significant effects were observed in the AC tests. A trend analysis revealed a significant trial-by-time interaction effect for heart rate, VO₂, and V_E during the graded exercise test (all P < 0.001). Lower VO₂ and V_E levels were exhibited in the exercise response of the smoking trial than in those of the control LC trials, whereas no discernable inter-trial difference was observed in the AC trials. Moreover, the differences in heart rate and V_E response between the LC and AC exercises were significantly smaller after the participants smoked.

Conclusion: This study verified that smoking significantly decreased performance and cardiorespiratory responses to leg exercises. However, the negative effects of smoking on arm exercise performance were not as pronounced.

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.

Changes in the expression and protein level of matrix metalloproteinases after exposure to waterpipe tobacco smoke

Waterpipe smoking has become a worldwide epidemic with health consequences that only now are beginning to be understood fully. Because waterpipe use involves inhaling a large volume of toxicant-laden smoke that can cause inflammation, some health consequences may include inflammation-mediated lung injury. Excess matrix metalloproteinase expression is a key step in the etiology of toxicant exposure-driven inflammation and injury. In this study, changes in the level and mRNA of major matrix metalloproteinases (MMP-1, -9, and -12) in the lungs of mice following exposure to waterpipe smoke were investigated. Balb/c mice were exposed to waterpipe smoke for one hour daily, over a period of 2 or 8 weeks. Control mice were exposed to fresh air only. ELISA and real-time PCR techniques were used to determine the protein and mRNA levels of MMP-1, -9, and -12 in the lungs. Our findings showed that MMP-1, -9, and -12 levels in the lung significantly increased after both 2 (p < 0.05) and 8 weeks (p < 0.01) exposures. Similarly, RT-PCR findings showed that mRNA of those proteinases significantly increased following 2 (p < 0.01) and 8 weeks (p < 0.001) exposures. In conclusion, waterpipe smoking is associated strongly with lung injury as measured by elevation in the expression of MMPs in the lung tissue.

Identification, characterization and antibiotic resistance of bacterial isolates obtained from waterpipe device hoses

The general lack of knowledge about the health effects of waterpipe smoking is among the reasons for its global spread. In this study, bacterial contamination of waterpipe hoses was investigated. Twenty hoses were collected from waterpipe cafés and screened for bacterial pathogens using standard culture and isolation techniques. Additionally, resistance of isolated bacteria to common antibiotics was determined by identifying the minimum inhibitory concentration (MIC) of each isolate. Forty eight bacterial isolates were detected. Isolates included both Gram-positive and Gram-negative pathogens from species that included Micrococcus (12), Corynebacterium (13) and Bacillus (9). In addition, some of the detected pathogens were found to be resistant to aztreonam (79%), cefixime (79%), norfloxacin, amoxicillin (47%), clarithromycin (46%) and enrofloxacin (38%). In conclusion, the hose of the waterpipe device is a good environment for the growth of bacterial pathogens, which can then be transmitted to users.

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.

Effect of shisha (waterpipe) smoking on lung functions and fractional exhaled nitric oxide (FeNO) among Saudi young adult shisha smokers

Shisha (waterpipe) smoking is becoming a more prevalent form of tobacco consumption, and is growing worldwide, particularly among the young generation in the Middle East. This cross-sectional study aimed to determine the effects of shisha smoking on lung functions and Fractional Exhaled Nitric Oxide (FeNO) among Saudi young adults. We recruited 146 apparently healthy male subjects (73 control and 73 shisha smokers). The exposed group consisted of male shisha smokers, with mean age 21.54 ± 0.41 (mean ± SEM) range 17-33 years. The control group consisted of similar number (73) of non-smokers with mean age 21.36 ± 0.19 (mean ± SEM) range 18-28 years. Between the groups we considered the factors like age, height, weight, gender, ethnicity and socioeconomic status to estimate the impact of shisha smoking on lung function and fractional exhaled nitric oxide. Lung function test was performed by using an Spirovit-SP-1 Electronic Spirometer. Fractional Exhaled Nitric Oxide (FeNO) was measured by using Niox Mino. A significant decrease in lung function parameters FEV1, FEV1/FVC Ratio, FEF-25%, FEF-50%, FEF-75% and FEF-75-85% was found among shisha smokers relative to their control group. There was also a significant reduction in the Fractional Exhaled Nitric Oxide among Shisha smokers compared to control group.