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Looking At Hookahs with An Objective Scientific Eye: The Health Factors and Science Behind Smoking the Hookah and Shisha

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Hookah (Shisha, Narghile, Waterpipe): An Objective Scientific Review in English
Hookah and Health : What You Should Know
Kamal CHAOUACHI
An AUTOMATIC quick translation of the original (French) Review on Narghile (Hookah, Shisha) by Kamal Chaouachi is offered to you. It was published in the prestigious journal “Le Courrier des Addictions” and gives an overview of what any honest lady or gentleman of this century should know about this topic.

CAUTION: it must be understood that this a machine generated translation (NOT HUMAN at all, lightly enhanced though by our editorial team) so we apologize in advance for the many linguistic errors it contains. The English-speaking reader is kindly asked to rephrase mentally what is not clear in the first instance. This said, we think it can be of a great help for those who want to have access to independent original scientific research on this hot topic since these materials are generally censored because they have not been published in English. However, the author said he will make an effort to publish directly in English language scientific journals. The original in French can be sent to anybody on request.
Since the middle of the years 1990, narghile suddenly became an increasingly known object of the public others that Asian and African. However, one had about it only of fragmentary and often anecdotic information until our publication of the first synthesis knowledge in 1997. Trained in socio-anthropology, the postgraduate degree of Tobaccology from Paris (1998) enabled us to apprehend the pharmacological, behavioural aspects and pathology related to the tobacco in general as well as the immense field of investigation opened by this form of use (doctoral thesis 2000). Today, the tobaccologists are sometimes asked about it. Also, this article is particularly intended to them.
DESCRIPTION
In spite of its diverse shapes and materials, 4 principal elements make up narghile now universally known under the name of “shisha” or “hookah”: the bowl with tobacco (in general of conical form), the stem (vertical tube of 75 cm to 120 cm on average) for drawing down the smoke from the bowl to the water, the water container (a kind of vessel with 500ml on average) and the suction hose (1,50m on average). Embers (natural or commercial quick-lighting charcoal) come to cap the tobacco-based mixture packed in the bowl. In the case of the tobamel (cf infra), an aluminium foil bored with several holes is interposed. Because of the depression induced by an aspiration in the hose, smoke is drawn down along the stem and undergoes a forced washing in the water. From there, it emerges on the surface of the liquid and engages, through an internal conduit of the mast, in the long hose before reaching the mouth of the smoker.
SMOKED PRODUCTS
Various preparations containing tobacco are used. The tobamel, the most widely spread, contains up to 70% of honey or molasses; from there its name (in arabic ‚Äúmu’essel‚Äù=with honey). The glycerin, as a moistener, constitutes also an essential ingredient as well as the essences of flowers or fruits: apple, cutter, rose, etc. The yields of nicotine and tar announced on the packs often vary around the zero… The tumb?¢k is made up mainly of leaves of tobacco, washed and dried several times then packed in the bowl to be heated directly by embers. With higher content of nicotine than the tobamel (Hadidi 2004), its preliminary washing should however contribute to decrease the rate of the alkaloid. The jur?¢k is an intermediate product: thick, blackish and not aromatised (cf Zahran 1982). As regards the users, the tobamel is in general more “female”, more “young” and more “urban” than the tumb?¢k or the jur?¢k.
THE CRAZE
The reasons of the vogue are numerous. Inter alia: tourists returning with one narghile in their suitcase, multiplication of the neo-orientalist lounges (narghile bars), self-incandescent charcoal with fast implementation; not irritated nonsmokers (filtering of acrolein and acetaldehyde [ Huber 1991 ]); anti-tobacco campaigns; mode of use considered as healthier than the cigarette; varied flavours… More subjectively, the term “social smoking” (very specific: long time of the meeting, shared pipe, bubbling of water, conversation, etc.) is systematically used.
HISTORY
The history of the object is surrounded by a certain halo of mystery and its origin is not necessarily Indian as certain authors affirm it. One can however fix the appearance of a use social, either individual, narghile, on a large scale, simultaneously with the appearance of the public coffee-houses and the adoption of the tobacco, roughly speaking with the turning of 16th and 17th century. Today, the most serious assumptions allot to him a South-African, Ethiopian origin or Persian (Chaouachi 2000).
PIONNEERS
40 years ago, Hoffmann measured the rate of filtration of certain components of the smoke of a shisha with tumb?¢k: phenol 90%, 50% of nicotine and benzo[a]pyrene of its particulate phase. At the same time, Rakower, intrigued by the very weak prevalence of the lung cancer among populations of users of the mad?¢’a (narghile with tumb?¢k), measured the rates of filtration of the tar: 84mg for 10g of tobacco and 161mg without water. In the seventies, Salem, another pioneer, led a number of impressive works on the g?ªza (Egyptian narghile of small size functioning with tabamel/jur?¢k).
PATHOLOGIES (Health Effects)
Perhaps this mode of use would reduce the risks of lung cancer (Hoffman, Rakower, Salem 1983 and 90, Gupta Dheeraj 2001, Tandon 1995, Lubin 1992, Hazelton 2001, Stirling 1979). Other pathologies like oral, gastric cancer and of the bladder, the eczema of contact, tuberculosis or aspergillosis, etc. (El-Hakim 1999, Gunaid 1995, Bedwani 1997, Onder 2002, Munckhof 2003, Salem 1973, Shadi 1985, Szyper-K. 2001) are not clearly established because of a non-rigorous methodology (simultaneous use of other products [e.g. q?¢t, cigarettes, etc ], strongly neglected hygiene, statute and career of the smokers not specified, etc). The use of narghile could however induce a significant increase in the oxydative stress in vivo (Wolfram 2003). Let us announce here that the water of the container could filter a variety of free radicals (Zaga 2003). Lastly, even with a degree lower than that of the cigarette or bidi, the smoke of the hookah would be genotoxic (but possible environmental factor) and clastogenic (Yadav 2000).
Kiter showed that the effects of narghile (tumb?¢k) on the pulmonary function would be less serious than those caused by cigarette (FEV1 and higher FEV1/FVC). In this same field, various studies tend to show that cigarette and shisha would produce similar harmful effects on the ventilatory capacity (Al-Fayez 1988). Whereas the cigarette smoke would affect the small respiratory tracts rather, that of narghile would have an effect on the large ways (Bakir 1991, Kiter). A high production of anion superoxyde (O2 _) in the neutrophiles, observed in India by Sharma 1997, raises also the question of the diet (antioxydants) of the committed volunteers.
Macaron noticed how heavy smokers using tumb?¢k “titrate” (compensation) by obtaining out of narghile all the nicotine they need (rates close to those of smokers of cigarettes). Shafagoj measured high rates of blood, salivary and urinary nicotine and cotinine of heavy smokers of narghile with tobamel (used in a rather intense way: 3 times per week) to whom an abstinence of 3 days and half was required before the experiment. The urinary rate of cotinine reported (249,79 +/- 54,78 ¬µg/24 H) is to be compared with those obtained by Macaron (700 to 33000 ¬µg/l (6.080 +/- 1.810 ¬µg/l)). The urinary nicotine rate is of (73,59 +/- 18,28 ¬µg/24 H). Between the beginning and the end of the session of narghile (45 min later), the average values of blood nicotine pass from 1,11 to 60,31 ng/ml. 3 hours later, the blood cotinine passed from 0,79 to 51,95 ng/ml. The average values of salivary nicotine and cotinine pass, respectively, of 1,05 to 624,74 ng/ml and 0,79 to 283,49 ng/ml. A recent study finally approached certain thermodynamic aspects (Shihadeh). The conditions (tobamel, non-natural quick-lighting coal, 100 puffs of 0,3l, 3s all 30 S) really did not correspond to reality (irregularity of smokes, etc).
The temperature of the tobamel, increasing, would reach 120¬?C to the maximum at the end of the meeting of 50min. As for the smoke filtered by water, it is at the ambient temperature. The case of the tumb?¢k, heated directly with 600-650¬?C is very different (cf Rakower). As for nicotine, a whole session would deliver to the smoker only the quantity obtained by 1 or 2 cigarettes. On the other hand, the quantities of tar obtained are high: for example 242mg (puffed out all 30s). Let us recall here that Hoffman and Rakower had recorded a rate of filtration of the tar of approximately 50%. However, because of the low temperatures concerned, the condensates would be more the product of a distillation than of a pyrolysis. Wynder (1958) thus showed that the carcinogenic character of smoke increases with the temperature, particularly starting from 800¬?C. See also White (2001) in connection with the genetic changes. Heat “enables chemical reactions between the aldehyde functions of sugars and the nitrogenous compounds, ammonia to start with, that the tobacco manufacturers use to give various aromatic compounds, as those which occur when one roasts meat. These flavours explain why the American cigarettes, where the tobacco is soaked in “sauces” containing molasses, little by little supplanted our traditional dark tobacco “(M., quoted in Chaouachi 2000).
Lastly, the study of Shihadeh records very high values for certain metals (Co, Pb, Have, Cr). Commercial coal used (unknown composition), the coating of the bowl and the stem or the aluminium foil probably play a role. As for lead, the results are apparently contradictory with those of a study of Salem (1990). In India, high levels of cadmium were recorded (Sukumar 1992) but factors of pollution are perhaps in question.
CARBON MONOXIDE
Coal, the tobacco and its molasses, the size of narghile contribute to the production of this gas. A rise in the carboxylemy seems acquired (Zahran 1985, Salem 1989). In Pakistan, Sajid showed that the CO rate rises in reverse ratio of the dimensions of the 4 principal elements of the device but also depends on the varieties of tobacco used. Thus, a rate equivalent to that of a simple cigarette can sometimes be measured. For expired CO, recent measurements (rather “heavy “smokers) reveal a high rate: 14,2ppm (Shafagoj).
DEPENDENCE
Recreational, dependent? Which tools to use for this mode of use (Chaouachi)? Passage of a collective use to an individual practice (Maziak)? Certain dependent individuals are able to refrain from smoking during several days. As they cannot get their usual tobamel or tumb?¢k, they generally do not have recourse, not only to the other of the two products, but yet to the cigarettes. Dependence on tobacco and not on nicotine, with a strong behavioral and even social variable ? And would the importance of the flavours of the tabamel imply a dependence similar to that of the coffee?
EPIDEMIOLOGY AND PREVENTION
In the Middle East, a quarter of the various categories of the population, without distinction, including the pregnant women (cf Nuwayhid 1998), indulge in narghile, in an recreational or regular way. In the majority of the countries of the Mediterranean basin, very concerned by the traditional use of the object, more than 45% from the men and 15% of the women would be smokers of cigarettes (Tessier 1999). Certainly, a significant proportion of the smokers selected in the recently surveys were simultaneous smokers of cigarettes, ex-users of these last or individuals “having substituted” a dependence by another. As for prevention, the religion is sometimes requested but without much success (Radwan 2003).
Two recommendations seem significant here to us. The first is that it is necessary to deter the cigarette smokers “to switch” to narghile (illusion due to titration (compensation)). The second is that commercial coal (self-quick-lighting) currently used, far from the areas of origin mainly (Asia and Africa), should be avoided. As for the cannabis, studies showed that aqueous filtering filtered… the cannabino?Ødes effectively (Savaki 1976, Lazaratou 1980). Research is directed towards a device which would make the economy of the coal and which would heat the plant around 200¬?C instead of burning it (Gieringer 2004).
CONCLUSION
Although the social use of narghile has more than 400 years of age, research in connection with it is late and this is why there does not exist yet programs of prevention worthy of this name. Probably, for reasons more sociocultural than pharmacological, the smoker of narghile seldom metamorphoses himself in a smoker of cigarettes. Thus, the world of narghile and that of the cigarette remain, a priori, strangers to each other. Practically, there is a fact that the researchers did not entirely assimilate yet; it is that it is important to study exclusive smokers of narghile and to reject as far as possible the simultaneous smokers of cigarettes, the ex-smokers of the latter product or those “having substituted” the practice of narghile. This last type of smoker is more exposed to the risks of dependence and absorption of quantities much more significant of elements normally reduced by narghile. It is also important, taking into account the high complexity of narghile, whose best point of view is at the fringes of the medical and sociocultural fields, to avoid, as far as possible, the quick comparisons with the cigarette. Lastly, because of the tobaccologic singularity of its mechanisms but also of the very diverse points of view that it offers to the researcher, narghile can, above all, help make enhance the comprehension of the phenomenon of dependence on cigarette.
Kamal Chaouachi © Shisha, hookah. Narghile in the XXIst century. An Overview of the Scientific Knowledge about it. Le Courrier des Addictions 2004 (Oct) ; 6 (4) : 150-2.

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