RESEARCH UPDATE ON NARGHILE. NADIM KANJ MD FCCP E mail :

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1 RESEARCH UPDATE ON NARGHILE NADIM KANJ MD FCCP E mail : dk01@aub.edu.lb

MAASSEL A new form of tobacco that came on the market in the 1990s In Syria, maassel is used exclusively by the vast majority of waterpipe users Maziak, W. et al (2004).

2 MAASSEL A new form of tobacco that came on the market in the 1990s In Syria, maassel is used exclusively by the vast majority of waterpipe users Maziak, W. et al (2004).International Journal of Tuberculosis and Lung Disease, 8, Most maassel made for export is produced in Bahrain and Egypt Tobacco is fermented with molasses and fruit essence Maassel is moist and pliable, making it easier to use than other waterpipe tobaccos, and it has a pleasant taste and aroma Kandela, P. (1997). Signs of trouble for hubble bubble. Lancet, 349, 9063 Kandela, P. (2000). Narghile smoking keeps Arabs in wonderland. Lancet, 356, 1175

3 EPIDEMIOLOGICAL STUDIES SMOKING MACHINE STUDIES SMOKING TOPOGRAPHY OUTLINE MEASURE THE AMOUNTS OF CARCINOGENS ASSOCIATION WITH CANCER EFFECT ON ORAL HEALTH OTHER EFFECTS CARBON MONOXIDE POISONING & CARBOXYHEMOGLOBIN CONCENTRATIONS COMPARATIVE ANALYSIS PULMONARY EFFECTS OF WATERPIPE SMOKING THE ACUTE EFFECTS OF WATER-PIPE SMOKING ON THE CARDIORESPIRATORY SYSTEM PREGNANCY OUTCOMES TOBACCO DEPENDENCE IN WATERPIPE SMOKERS WHY DO WE NEED TO STUDY NARGHILE? AND WHAT?

4 Tobacco Use Among Students Aged Years --- Baghdad, Iraq, % Cairo University medical students 17.6% College Athletes in the United States Pittsburgh, % college students Michigan, % of males and 52% of females reporting ever smoking tobacco using a waterpipe and 22% of males and 5% of females reporting current waterpipe smoking. Of the sample, 28% of males and 10% of females were current cigarette smokers and 25% of males and 10% of females were current marijuana users Arab American Adolescent %; it increased from 23% at 14 years to 40% at 18 years Arab American students ; water pipe smoking than cigarettes (38% vs. 22%), and more current (16% vs. 6%) and regular (7% vs. 3%) use of water pipes than cigarettes Pregnant women in Lebanon 2004,4% smoking only argileh, and 1.5% smoking both cigarette and argileh 12.9% had ever smoked shisha Baghdad, Iraq, 2008 Cairo University medical students current users of water pipe sheesha comprised 17.6% % of students at one British university were regular waterpipe smokers, students at the American University of Beirut 28.3% were current argileh smokers, average initiation age was 16 years ,652 students, Al Hassa, Saudi Arabia WP (37.4%) Worldwide,an estimated 100 million daily users Practiced by approximately 1 billion people ,430 UAE nationals aged 18 years shisha (waterpipe) (6.8%), 2010

5 PREVALENCE AMONG YOUTH 2011 Martinasek M et al.curr Probl Pediatr Adolesc Health Care 2011;41:34-57

6 BREATHE study 2012 Middle East and North Africa Khattab A et al.respiratory Medicine (2012) 106(S2), S16 S24

7 A. Shihadeh. Food and Chemical Toxicology 41 (2003) A standard smoking session was defined as 100 puffs, duration 3 s, with 30 s between puffs (i.e. a cycle period of 33 s) A smoking machine was designed and smoke from an argileh fueled with charcoal and loaded with 10 g of mo assel tobacco mixture was generated using puffing parameters selected to approximate those of argileh smokers. The importance of the argileh water was tested by including a condition where no water was present in the bowl Smoking Machine Apparatus

2005 ma assel narghile smoke condensates Cigarette smokers typically take 8 12 puffs of 40 75 ml in about 5 7 min and inhale 0.5 0.

9 2005 ma assel narghile smoke condensates Cigarette smokers typically take 8 12 puffs of ml in about 5 7 min and inhale liters of smoke WPS sessions min, puffs, intake ranging from about 0.15 to 1 liter each session The water pipe smoker may therefore inhale the equivalent of 100 or more cigarettes 100-fold more tar, 4-fold more nicotine, 11-fold more CO, and 2- to 5-fold more polycyclic aromatic hydrocarbons than did a single cigarette

Randomized, 2 arm, Crossover study MAY 2013 Nakhla Al-Waha URINARY EXCRETION OF TOXIC SUBSTANCE BIOMARKERS 4 inpatient days & ad libitum Water pipe for

10 Randomized, 2 arm, Crossover study MAY 2013 Nakhla Al-Waha URINARY EXCRETION OF TOXIC SUBSTANCE BIOMARKERS 4 inpatient days & ad libitum Water pipe for a minimum of twice per day CPD number and weight of cigarettes smoked or weight of water pipe tobacco smoked, times, duration, and number of sessions >

11 2013 Smoke from water-pipes contains most of the compounds that are also present in cigarette smoke, although in different proportions More importantly, the longer duration of a WPS session leads to a much higher yield of toxic molecules than cigarette smoking We believe that current water-pipe and tobacco smoking are important risk factors in the initiation of cancer invasion and metastasis through the epithelial mesenchymal transition (EMT) event and deregulation of its key genes More molecular and cellular biological studies are necessary to determine the exact role of tobacco and WPS in the progression of several human carcinomas

Oral squamous cell carcinoma (OSCC) El-Hakim I E et

carcinogenic chemicals Mechanical trauma

mouth piece) Heat generated from the smoke Chronic

one narghile by several individuals N. S.

12 Oral squamous cell carcinoma (OSCC) El-Hakim I E et al Int J Dermatol 1999; 38: Exposure to carcinogenic chemicals Mechanical trauma (irritation by the bamboo Plastic tubes used in the mouth piece) Heat generated from the smoke Chronic infection that would be associated with the use of one narghile by several individuals N. S. Dar-Odeh and O. A. Abu-Hammad.BRITISH DENTAL JOURNAL 206 NO. 11 JUN

13 2010 A significant association was found with Plaque and gingival indices Bone loss among water pipe only smokers vs. non smokers, OR rising to 7.5 (95% CI ) among heavy users Pocket depth (>10 sites with a probing depth >5mm) OR of 5.1(95% CI ) for WPS

14 Cardiovascular disease Acute coronary syndrome Hematologic disturbances OTHER EFFECTS Shafagoj & Mohammed, 2002 Jabbour, El-Roueiheb, & Sibai, 2003 Israel et al., 2003 Jassim Al Suwaidi et al. Postgrad Med J 2012;88: Sharma et al., 1997 Single water pipe smoking induces oxidation injury as evidenced by various markers Repeated daily smoking induces a persistent longer-lasting oxidation injury Wolfram R et al. Life Sciences 74 (2003) Hookah (narghile) smoking: A new emerging cause of secondary polycythemia SCHUSTER S et al. American Journal of Hematology 2011 Genetic abnormalities Yadav & Thakur, 2000 El-Setouhy M, et al.mutat Res 2008 Rammah M, Dandachi F, Salman R, Shihadeh A, El-Sabban M.. Toxicol Lett 2012;211(3): Alsatari ES, et al. Int J Occup Med Environ Health 2012;25(3): Waterpipe Smoking And The DRD2/ANKK1 Genotype Radwan GN et al. J Egypt Public Assoc 2010;85(3-4): Infectious diseases Potential to be linked to multiple communicable infectious diseases, including herpes simplex virus, Epstein-Barr virus, and respiratory viruses, from sharing waterpipes and mouthpieces on the hose, a common practice of waterpipe smoking Tuberculosis, due to the sharing of the waterpipe among smokers Knishkowy & Amitai, 2005 Salem et al Israel et al.2003 World Health Organization [WHO], 2005 Munckhof W J, et al. Int J Tuberc Lung Dis 2003; 7: Meleigy M. Lancet Infect Dis 2007;7:448

intake More CO particles since coal is used to burn the tobacco Generally takes place in closed environments

15 Karaca Y, et al. BMJ Case Rep 2013 Water pipe smoking is a lengthy process Users receive a greater volume of smoke with every intake More CO particles since coal is used to burn the tobacco Generally takes place in closed environments Smokers are also continuously exposed to emitted particles It takes an average of 1 h to smoke a water pipe Exposure to CO is approximately seven times greater compared with cigarettes COHb level 32.7%.

16 Standard Protocol for an average 1 h for Machinesmoked Waterpipe and 5 min for a Cigarette 2013 Comparison of Smoke Toxicants Yield

2011 Comparison of FEV 1 /FVC in water-pipe smokers and nonsmokers Al Mutairi SS,. Respirology. 2006 ; 11 ( 4 ): 449-455 Kiter G. Respir Med.

17 2011 Comparison of FEV 1 /FVC in water-pipe smokers and nonsmokers Al Mutairi SS,. Respirology ; 11 ( 4 ): Kiter G. Respir Med ; 94 ( 9 ): Al-Fayez SF, Trop Geogr Med. 1988; 40( 2): Aydin A,. Ann Nucl Med ; 18 ( 4 ): Mohammad Y Int J Chron Obstruct Pulmon Dis ; 3 ( 3 ): Köseo ğlu N, Tuberk Toraks ; 54 ( 3 ):

18 Acute biologic changes that might result in marked health problems 2011

19 Several factors may explain this relatively low level of interest in quitting waterpipe use Underappreciation of adverse health effects Perceive to be less harmful to health than cigarettes (Kandela, 2000) Maassel, is aromatic and when passed through water delivers a cool, smooth smoke, making it is easy to see how such a perception could arise Social norms that support waterpipe use Perception that waterpipes are easy to quit and not addictive

20 2007

Jawad M, et al.british Journal of General Practice, February 2012 No legislation on the tobacco used in shisha beyond its prohibition indoors Knishknowy B, Amitai Y.

Tob Control 2010; 19(3): 235 239 Tobacco is not usually fully consumed Shihadeh A.

21 Jawad M, et al.british Journal of General Practice, February 2012 No legislation on the tobacco used in shisha beyond its prohibition indoors Knishknowy B, Amitai Y. Pediatrics 2005; 116(1): Many shisha tobacco companies do not even display the tobacco content contained within Nakkash R, Khalil J. Tob Control 2010; 19(3): Tobacco is not usually fully consumed Shihadeh A. Food ChemToxicol 2003; 41(1): TITRATION : shisha users are able to titrate up and down the tobacco based on smoking preference and level of nicotine addiction Salameh P et al. Nicotine Tob Res 2008; 10(1): Documented evidence of shisha smokers experiencing cravings and withdrawal symptoms MaziakW, et al.nicotinetob Res 2009; 11(7): Shisha has been used both as a precursor to and a substitute for cigarettes Hammal F, et al. Tob Control 2008; 17(2): e3 Jensen P, et al.subst Use Misuse 2010; 45(7 8):

22 Re-evaluate and re-educate Ask the Shisha Question Attempt to quantify shisha use Joining calls for more research

23 2013 JOANNA KHALIL, RIMA AFIFI, FOUAD M. FOUAD, FADI HAMMAL, YARA JARALLAH, MOSTAFA MOHAMED, RIMA NAKKASH Understanding the social aspects of waterpipe tobacco smoking is crucial to planning future interventions to control waterpipe tobacco smoking among women and in society at large

24 THANK YOU

FORMs of TOBACCO. 2 nd of 3 Prep for Session 1

FORMs of TOBACCO. 2 nd of 3 Prep for Session 1 FORMs of TOBACCO 2 nd of 3 Prep for Session 1 FORMS of TOBACCO Cigarettes Spit tobacco (chewing tobacco, oral snuff) All forms of tobacco are harmful. Pipes Cigars Clove cigarettes Bidis Hookah (waterpipe)