01477632979CirculationCirculationCirculation0009-73221524-453930845826660081210.1161/CIR.0000000000000671HHSPA1033936ArticleWater Pipe (Hookah) Smoking and Cardiovascular Disease
RiskA Scientific Statement From the American Heart AssociationBhatnagarAruniPhD, FAHAMaziakChair WasimPhDEissenbergThomasPhDWardKenneth D.PhDThurstonGeorgeScDKingBrian A.PhD, MPHSutfinErin L.PhDCobbCaroline O.PhDGriffithsMerlynPhDGoldsteinLarry B.MD, FAHARezk-HannaMaryPhDOn behalf of the American Heart Association Behavioral Change for
Improving Health Factors Committee of the Council on Lifestyle and
Cardiometabolic Health and Council on Epidemiology and Prevention; Council on
Cardiovascular and Stroke Nursing; Council on Quality of Care andOutcomes
Research; and Stroke Council20620190752019075202013919e917e936
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.
AHA Scientific Statementscardiovascular diseaseepidemiologynicotineparticulate mattersmoking water pipestobaccovolatile organic compounds
Recent estimates suggest that between 0.85 and 1.1 billion people use tobacco
products world-wide.1 These products
include cigarettes, cigars, cigarillos, pipes, water pipes, and smokeless tobacco. The
global use of electronic cigarettes (e-cigarettes) remains unknown, but among the
tobacco products queried, manufactured cigarettes are favored by most smokers (82%). The
use of tobacco is particularly high in middle-income countries such as China, India, and
Russia. Nearly 300 million individuals in China and 275 million in India use tobacco
products daily.1 In countries such as
Russia and the Ukraine, 50% to 60% of adult men use some form of tobacco.1 The use of tobacco products is also high
in high-income countries such as the United States and the United Kingdom. Although
there have been significant declines in the rate of tobacco product use in some
countries, an increase in population has led the number of cigarette smokers worldwide
to grow from 721 million in 1980 to 967 million in 2012.2 Tobacco, therefore, is likely to remain a major
global public health threat for the foreseeable future.
Tobacco use remains a leading cause of disease and premature death. The World
Health Organization estimates that tobacco accounts for 9% of deaths
world-wide3 and that globally
nearly 6 million people die of tobacco-related causes every year.4 To date, nearly 100 million deaths are
attributable to tobacco use, and if current use patterns persist, tobacco use could kill
>1 billion people in this century.4 Extensive literature documents the adverse health effects of tobacco
use, and although cigarette smoking increases the risk of many chronic illnesses,
cardiovascular disease (CVD; inclusive of stroke) remains a leading cause of death in
smokers.5 In the United States,
as many as 30% of the all coronary heart disease deaths each year are related to
cigarette smoking,6 and smoking doubles
the risk of premature cardiovascular mortality.7
As a result of the recognition of the high impact of tobacco use on
cardiovascular health, tobacco control efforts are underway worldwide. In the United
States, the American Heart Association (AHA) supports the implementation of proven
population-based tobacco control interventions, including antitobacco mass media
campaigns and comprehensive smoke-free laws at the state and local levels. Proven
tobacco prevention and control measures, including comprehensive clean indoor air laws,
increases in tobacco product prices, restriction of tobacco sales to those ≥21
years of age, and US Food and Drug Administration regulation of tobacco products, are
critical population-based strategies endorsed by the AHA.8 The AHA identifies never having tried smoking and
never having smoked or having quit >12 months as 1 of the 7 components of ideal
cardiovascular health in Lifés Simple 7, selected on the basis of their
contributions to incident CVD.9
Although the AHA has published policy statements on smokeless tobacco10 and e-cigarettes,11 to date, no AHA scientific statement has
addressed the cardiovascular impact of water pipe tobacco smoking. Hence, the objectives
of this statement are to describe the design and operation of water pipes and the
patterns of use by adults and youths, to identify different harmful or potentially
harmful constituents (HPHCs) of water pipe smoke, and to review potential cardiovascular
effects of water pipe use. The statement also offers a broad range of proven strategies
to reduce and prevent water pipe tobacco use and associated adverse cardiovascular
effects, discusses knowledge gaps that still need to be addressed, and provides concrete
guidance to health-care providers for the identification and treatment of patients who
smoke water pipes.
DESIGN AND OPERATION
Water pipe that is used to smoke tobacco is known by many different terms,
including hookah, narghile, argileh, shisha, and
goza. This review uses the term water pipe to
universally denote this product class. Over the years, the water pipe has had a
variety of configurations, but as used today, it consists of a head or bowl (where
tobacco is placed), a body, a water base, and a hose that ends with a mouthpiece
(Figure 1). Burning charcoal
briquettes/pieces are placed on top of the tobacco-filled bowl, which is usually
made of clay, marble, or glass. The charcoal pieces are often separated from the
tobacco by a perforated aluminum foil to allow the heated air to pass through the
tobacco, and the holes in the bottom of the head allow the smoke to pass down
through the stem, which can be of varying sizes and lengths. The down stem is
immersed in water to allow smoke to bubble through, which cools and humidifies the
smoke. Sometimes, mint leaves, fruits, or crushed ice are added to the water. Smoke
emerging from the water passes through a hose, usually made of leather, vinyl, or
plastic, which allows the smoke to be drawn by the user. Some water pipes have rigid
mouth-piece reeds, whereas others may have multiple hose ports for simultaneous use
by several smokers. The end of the hose is usually capped by a metal, wooden, or
plastic mouth tip that can be covered by a disposable mouthpiece (to allow multiple
users and repeated use of the same water pipe hose).
Both the water pipe design and use patterns can affect smoke constituents and
flavor. During a smoking session, the charcoal briquettes are adjusted and
replenished to maintain the desired taste, smoke concentration, and smoke volume.
Either natural or quick-lighting charcoals, which are combusted, are used to heat
the tobacco. Although not systematically studied, the extent of nicotine generated
from tobacco is likely affected by the heating temperature, tobacco mixture used
(including flavors, humectants, and additives), puffing topography, water pipe size,
and amount of water in the water pipe bowl.13,14 Water pipe
tobacco is usually a combination of dried fruit, tobacco, and humectants. Data from
many countries show that maassel is the currently preferred form of
tobacco for water pipe smokers, especially among youth and young adults.12,15–18Maassel (Arabic for honeyed) is a sweetened and flavored tobacco
mixture. Before the introduction of maassel, most water pipe
smokers globally used some form of raw tobacco that was crushed, mixed with water,
squeezed, and molded before use.12
Unlike the smooth aromatic smoke produced from maassel, this method
usually produces a strong, harsh smoke.12 In the United States, nearly 90% of youth use flavored
tobacco when smoking a water pipe.16,19
Water pipes and their components (eg, charcoal, devices, and tobacco) and
accessories can be purchased from dedicated supply shops and increasingly from
internet vendors.19 Some vendors
claim that the harmful effects of water pipe smoking are reduced by using
accessories such as electronic heaters, mouthpiece Alters, water additives, and mesh
fittings to create smaller bubbles. However, the veracity of these claims remains
uncertain. Conventional water pipes are different from the electronic devices known
as e-hookahs, e-shisha, or hookah pens, which are
electronic nicotine delivery systems that involve heating of a liquid (often
containing nicotine) that can be flavored to mimic the taste of flavored water pipe
tobacco. These electronic devices do not involve the use of water pipe tobacco
products/mixtures or charcoal combustion, 2 main features of conventional water
pipes.
Water pipe tobacco is sold in a wide variety of flavors, including apple,
banana, berry, cherry, chocolate, coconut, coffee, cola, grape, kiwi, lemon,
licorice, mango, mint, orange, peach, pineapple, rose, strawberry, tutti fruity,
vanilla, and watermelon.20 The
names given to water pipe tobacco leverage the positive association that people have
with fruit, desserts, soft drinks, and candy. Flavored products are sold in colorful
packaging that usually does not carry health warnings and are targeted to younger
consumers.21,22 The sweetened aroma of water pipe tobacco is
not as harsh as cigarette smoke, and water pipe tobacco is associated with less
throat and upper respiratory tract irritation, thereby masking the harshness of the
tobacco smoke and making it easier to start and continue smoking.16,23
EPIDEMIOLOGYPatterns of Water Pipe Smoking Among YouthPrevalence of Use
The worldwide use of water pipes is extensive. In the 2016 NYTS
(National Youth Tobacco Survey), a US nationally representative school-based
study, 4.8% (95% CI, 4.1–5.7%) of high school students (n=700 000)
reported smoking tobacco using a water pipe over the prior 30 days, with
similar rates among male (4.5%) and female (5.1%) students.24 In the 2016 MTF survey
(Monitoring the Future), 13.0% of 12th graders reported water pipe tobacco
use in the past year, with boys (15%) more likely to report water pipe use
than girls (11%).25 In
wave 1 (2013–2014) data from the PATH study (Population Assessment of
Tobacco and Health) of >13 000 youths 12 to 17 years of
age,26 7.5% (95%
CI, 6.8–8.2) reported ever water pipe use, and 1.7% reported smoking
water pipe tobacco in the prior 30 days. Ever use and past-30-day use were
higher among 15- to 17-year-olds (13.0% and 2.9%, respectively) than 12- to
14-year-olds (2.0% and 0.5%, respectively). Ever water pipe use was higher
among bisexual (19.3%) and gay/lesbian (17.7%) 14- to 17-year-olds than
those identified as heterosexual (10.4%). Ever water pipe use was comparable
between male (7.1%) and female (7.8%) participants but increased with each
year of age.26
Trends in Use
The NYTS found a nonlinear increase in past-30-day (current) water
pipe tobacco use among high school students (4.1% to 4.8%) between 2011 and
201624; past-30-day use among high school students increased
between 2011 and 2014; and use peaked at 9.4% in 2014 before declining to
4.8% in 2016. The MTF study found a steady increase in annual water pipe use
among 12th graders from 2010 (17.1%) to 2014 (22.9%), followed by a decrease
in 2015 (19.8%) and 2016 (13.0%).25 Reasons for this decline remain unclear.
International Use
The spread of water pipe use among younger populations is global.
Data from the Global Youth Tobacco Survey, which included 13- to
15-year-olds in 7 Middle Eastern countries, showed that the rates of water
pipe smoking ranged from 9% to 15%, which were higher than cigarette smoking
rates in almost all countries studied.27 Studies from some countries now show that water
pipe tobacco smoking is eclipsing cigarette smoking. For example, a study of
students in the United Kingdom during 2011 to 2012 found that current water
pipe use was more than twice as common as cigarette smoking (7.6% versus
3.4%).28
Characteristics of Water Pipe Smoking Among YouthFlavored Use
Data from the 2014 NYTS revealed that 63.8% of high school students
who reported water pipe use within the prior 30 days smoked flavored
tobacco. Data from wave 1 of the PATH study showed that among youth 12 to 17
years of age, 89% of those who had ever used water pipe reported that their
first use involved a flavored product.29
Frequency of Use
Most youth use water pipes intermittently. Data from PATH wave 1
revealed that <1% (0.1%) of youth 12 to years of age use water pipe
daily.26
Polytobacco Use
The PATH wave 1 data showed that 43% of youth who used tobacco in
the past 30 days used >1 tobacco product. Of the 116 different
product combinations, the combination of e-cigarettes and water pipe was the
third most common one reported (5% of past-30-day tobacco users). An
additional 4% of past-30-day tobacco users reported smoking cigarettes and
water pipe, and 3% used cigarettes, e-cigarettes, and water pipes.26 Longitudinal studies in
the Middle East found that the risk of initiation of cigarette smoking was
higher among water pipe smokers than among never smokers (adjusted hazard
ratio, 1.67 [95% CI, 1.46–1.92]) and that the risk increased with the
frequency of water pipe smoking.30
Reasons for and Perceptions About Water Pipe Smoking Among YouthReasons for Use
Youths cite several reasons for water pipe use: entertainment,
relaxation, boredom, curiosity, and somatic experiences, including the
pleasant taste and smell, as well as tactile and visual elements,
specifically the voluminous smoke.15 Culture is often cited as a reason for use among
those from the Middle East, although for many years, use was largely
confined to older men. However, use became more prominent among young people
in the 1990s with the introduction and mass marketing of flavored water pipe
tobacco.31 Youth
indicate that water pipe smoking allows them to meet others with a shared
cultural background.32
Data from wave 1 of PATH found that 12- to 17-year-olds reported using water
pipes use for several reasons, including the following: ˝I like
socializing while using them˝ (80%); ˝comes in flavors I
like˝ (79%); ˝less harmful to me than cigarettes˝
(61%); ˝affordability˝ (44%); and ˝people who are
important to me use them˝ (36%).29
Perceptions About Use
Water pipe use among youth is influenced by perceptions of its
addictiveness and harm. Many youth believe that the chance of becoming
addicted to water pipe is low, perhaps because of their intermittent use
patterns.29 The
youth also perceive a lower risk of health harms associated with water pipe
smoking compared with cigarette smoking. For example, youth water pipe users
and nonusers often believe that it is safer than smoking cigarettes because
they think that the water ˝filters out toxins.˝33,34 The wide variety of flavors of water pipe tobacco
and the cooling features of the water produce a mild smoke, which may lead
to misperceptions of safety.16 Youth also cite the absence of health warnings and
media campaigns describing harms as a reason that they perceive water pipes
to be a safer tobacco product.16
Interest in Water Pipe Smoking
The increasing interest in water pipe smoking is evident from the
volume of related online searches. Between January 2004 and December 2013,
water pipe online shopping searches increased by 291%, with
hookah being the most common water pipe search term
(190 000 average weekly searches), followed by shisha (127
000 searches). Other relevant searches include Starbuzz, which is a common
brand of water pipe tobacco and accessories. Comparing the relative search
volume in 2013 for water pipe across the United States, United Kingdom,
Australia, and Canada shows that the online interest in water pipe was
highest in the United States (100% relative search volume, December 2013),
followed by the United Kingdom (48.2% mean weekly relative search volume for
2013), Canada (42.6%), and Australia (27.2%).35
Growth in water pipe establishments or lounges as key places for
smoking continues, with many locations in areas of high population density
or near colleges and universities. In 2011, there were an estimated 725
US-based water pipe establishments with at least 1 location in 43 states and
the District of Columbia.34 By 2015, 1690 US water pipe establishments were
reported, primarily in large metropolitan areas (ie, Los Angeles, New York,
Chicago, Atlanta, and Miami). Most of these establishments were within 3 to
9 miles of college or university campuses with a student population of
≥20 000.36 These
establishments or lounges could also influence youth interest in and use of
these products. Nearly 30% of high school students in San Diego learned
about water pipe smoking by seeing a water pipe lounge, and current water
pipe users were more likely to know of a water pipe lounge in their
community.37
Furthermore, lounges have reinforced pro-water pipe messages in
advertisements and on social networking sites.38
Influence of Social Media
Pro–water pipe messages on social media, which are widespread
and unregulated, are likely to add to the proliferation of water pipe use. A
study of the profiles of 307 Facebook users, recruited from among students
at 2 US universities, found that 27.8% of participants had ever smoked water
pipe and 5.3% of the profiles contained water pipe references.36 Water pipe users reported
smoking tobacco (78%), hash (12%), or both tobacco and marijuana/hash (10%)
in their apparatus. There were no significant differences in water pipe use
based on age, sex, or race.39 Nearly a quarter of the pro-water pipe tweets on
Twitter are commercial promotions of water pipe at bars, clubs, events, and
other venues, encouraging the social aspects of water pipe that appeal to
young people.40 In 2014,
>12 000 water pipe–related tweets were sent daily, mostly from
Twitter users with high influence and many who are pro water pipe.
Eighty-seven percent of these tweets normalized water pipe or promoted its
use, whereas 7% were against water pipe or discouraged its use.41 Positive tweets from
individuals tend to emphasize the enjoyable experience of water pipe
smoking, and tweets from business entities often highlight the potential to
have a positive water pipe smoking experience.42
A vast majority of the water pipe pins on Pinterest are
image-based40 and
more often portray water pipe smoking in a more positive than negative
light, which tends to trigger more repins, likes, and higher levels of
engagement.43 On
YouTube, water pipe–related videos are more likely than
cigarette-related videos to portray tobacco use positively, to describe
smoking water pipe tricks, and to provide practical information on how to
smoke water pipe. Some videos frame water pipe preparation as an art form or
hobby, requiring patience and experience to cultivate and perfect.44
Enticement to engage in water pipe use by water pipe establishments
has been depicted on photo-based and microblog websites. For example, a
recent study of water pipe promotion and use on Instagram found
cross-promotion of water pipe and alcohol use by water pipe establishments,
suggesting that these venues regularly depict and promote polysubstance
use.45 On Tumblr,
the most prominent features portrayed by those who post include references
to or images of water pipes, sexuality, socializing, alcohol, water pipe
smoke, and tricks performed with the water pipe smoke.46
Patterns of Water Pipe Smoking Among AdultsPrevalence of Use
Water pipe use varies across population subgroups. During 2013 to
2014, the proportion of US adults (age >18 years) who reported using
a water pipe in the NATS (National Adult Tobacco Survey) everyday, some
days, or rarely was 4.3%, which translates to ≈10 million
adults.47 The
proportion who reported at least some frequency of water pipe use varied
with sociodemographic groups, most notably with age. Prevalence was highest
among those 18 to 24 years of age (13.6%) compared with those 25 to 44
(9.0%), 45 to 64 (4.7%), or ≥65 (1.5%) years of age. Young adults, 18
to 24 years of age, accounted for 55.8% of water pipe smokers
nationwide.47
Trends in Use
Although water pipe use has generally increased over time, this
pattern has varied with age. In the United States, data on trends in adult
water pipe tobacco use are limited given that questions about these products
were first added to national surveys beginning in 2009 to 2010 and that
different definitions, methods, and samples were used in different
populations over time. Findings from the NATS indicate that past-30-day
(current) water pipe use among US adults has generally increased from 1.5%
during 2009 to 2010 to 3.2% in 2013 to 2014.47,48 This increase was driven largely by young adults, with
prevalence among those 18 to 24 years of age increasing from 7.8% in 2009 to
2010 to 15.8% in 2013 to 2014.47,48
International Use
Outside the United States, data on prevalence and trends of water
pipe use indicate markedly increasing interest in these products, including
among adults. The worldwide prevalence of hookah use12,49–53 is
shown in Figure 2. The rates of current
use, however, are generally lower among adults compared with young
people.12
Moreover, use varies considerably across countries and regions.12,54 Among individuals ≥15 years of age from 44
countries who participated in the Global Adult Tobacco Survey or the Special
Eurobarometer 385 during 2008 to 2012, there was virtually no water pipe
smoking in assessed countries from the Americas, Southeast Asia, and
Africa.54 Within
the Eastern Mediterranean region, prevalence of current water pipe use was
3.3% in Egypt.54 In the
Western Pacific region, prevalence ranged from virtually no use in China,
the Philippines, and Malaysia to 6.4% in Vietnam.54 Some of the countries with the
highest prevalence of adult water pipe smoking are located in Europe;
current use was highest in Denmark (8.4%), Cyprus (8.5%), Lithuania (9.0%),
and Latvia (11.5%).54
Across many countries and regions, current use of water pipes is generally
higher / among men than among women.54
Characteristics of Water Pipe Smoking Among AdultsFlavored Use
Flavored tobacco is commonly used by water pipe smokers. During 2013
to 2014, an estimated 82.3% of US adults assessed via the NATS who used
water pipe in the prior 30 days reported using a flavored product.55 Among users, the most
prevalent flavor used was fruit (74.0%), followed by menthol/mint (18.9%),
candy/chocolate/other sweet (17.4%), clove/spice/herb (4.3%), alcohol
(3.2%), and other (3.0%).55 Among those who used water pipe in the past 30 days,
flavored use was similar among men (81.3%) and women (83.6%) and generally
decreased with age. Among 18- to 24-year-olds who used a water pipe in the
past 30 days, flavored product use was 85.9% compared with 66.8% among 45-
to 64-year-olds.55
Flavored use did not vary by race/ethnicity.55 Flavored use ranged from 81.1% among
those with annual household income of >$100 000 to 85.4% among those
with annual household income of <$20 000.55 Among past-30- day users, the
prevalence of flavored use ranged from 75.2% among those with a
bachelor’s degree or higher to 83.9% among those with less than a
high school diploma.55
Flavored use was 89.6% among lesbian, gay, or bisexual adults compared with
81.2% among heterosexual adults.55 By US region, flavored use was 77.7% in the West,
82.1% in the South, 86.1% in the Midwest, and 86.3% in the
Northeast.55
During 2013 to 2014, the prevalence of flavored water pipe use was 83.8%
among current cigarette smokers, 82.2% among recent former cigarette
smokers, 81.2% among long-term former cigarette smokers, and 81.4% among
never cigarette smokers.55
Frequency of Use
Many water pipe users also partake of other tobacco products. During
2013 to 2014, the proportion of US adults assessed via the NATS who reported
using a water pipe every day or some days was 0.6% (1.4 million adults);
with the inclusion of adults who reported that they rarely use a water pipe,
the proportion increased to 4.3% (10.0 million adults).47 Among adults who smoked during the
prior 30 days, the use of flavored water pipe was more common among
some-days users (91.7%) compared with rare users (80.8%).55
Polytobacco Use
Among US adults who reported using tobacco during 2013 to 2014
assessed via the PATH survey, 62.2% used 1, 22.5% used 2, and 15.3% used
≥3 types of tobacco products.26 Among the 331 reported combinations of polytobacco
use among US adult tobacco users, the combination of cigarettes and
e-cigarettes was the most common (23%), followed by the use of cigarettes
and water pipes (6%).26 In
addition, 3% of US adult tobacco users reported current cigarette,
e-cigarette, and water pipe use; 2% reported current e-cigarette and water
pipe use; 2% reported current cigarillo and water pipe use; and 1% reported
traditional cigar and water pipe use.26 Current water pipe tobacco smoking is associated
with increased risk of cigarette smoking among young adults; among those who
had never smoked cigarettes, those who smoked water pipe at least rarely
were 2.3 times more likely to begin cigarette smoking compared with those
who were not current water pipe smokers.56
Reasons for and Perceptions About Water Pipe Smoking Among AdultsReasons for Use
Multiple reasons have been cited for water pipe tobacco smoking,
including social and cultural acceptability. More specifically, some adult water
pipe smokers, particularly those from the Middle East or of Middle Eastern
descent, report that water pipe use is rooted in their cultural traditions and
occurs during family and other social gatherings.57 Additional factors influencing water
pipe use include ease of access through family, friends, and storefronts such as
cafés and bars.57 In
addition, promotion of water pipes through traditional advertising, the
internet, and social networks is a driver for water pipe initiation and use,
particularly among younger adults.57 Finally, some studies suggest that smoking water pipe may
have self-perceived positive psychological effects on users, including improved
concentration and self-efficiency, as well as reductions in stress, anger, and
depression,57 perhaps
in part as a result of nicotine exposure, which can increase attention and
scores in vigilance tasks.58
Perceptions About Use
The use of water pipes among adults may be influenced by
misperceptions about its addictiveness and health risks, particularly among
younger adults.57 For
example, some users perceive that the probability of addiction is low if the
product is used occasionally, and most users believe that they can easily
quit water pipe smoking.57
There is evidence, however, that adolescent water pipe users begin
exhibiting signs of dependence relatively quickly (<1 year after
their first use) and when smoking only occasionally (7.5 water pipes per
month or 6 d/mo, on average).59 The initiation and use of water pipes might also be
influenced by perceptions of the risk of smoking water pipes compared with
cigarettes.For example, 1 study found that the majority of water pipe users
(58.3%) perceived water pipe smoking to be less harmful than cigarette
smoking, with more frequent users being more likely to have this
perception.60 This
perception could be based on the belief that these products contain less
nicotine and harmful chemicals than cigarettes because the smoke passes
through water.57 Other
studies, however, indicate that some users consider the risk of smoking
water pipe to be equal to or more than that of smoking cigarettes57 and that individuals who
receive educational information about the harms of water pipe smoking report
greater perceived risk about the use of these products.61
WATER PIPE SMOKE CONSTITUENTS
The range of HPHCs found in water pipe tobacco smoke is similar to that of
the chemicals found in the smoke of combustible cigarettes.53 There are, however, important differences.
The HPHC profiles of water pipes differ from those of cigarettes because of the use
of charcoal to heat the tobacco, the temperature at which the tobacco is heated or
burned, and the volume of delivered smoke.53 Moreover, the patterns of water pipe use and cigarette
smoking differ, resulting in differing exposures. In water pipes, tobacco is heated
to ≈450°C with typical quick-lighting charcoal, which is lower than
the temperature in cigarettes (≈900°C).13 Thus, the temperature attained in water
pipes is usually below that required for pyrolysis or outright combustion.
Nevertheless, under standard smoking machine protocols based on Middle Eastern
smoking patterns (which may be different from those in the United States),13 a single water pipe smoking
session generates on average 70 times higher levels of tar, 2.5 times greater levels
of phenanthrene, and 11-fold higher levels of carbon monoxide (CO) than cigarettes.
Even when normalized per 1 mg of nicotine in the tobacco, the CO yield is
≈3-fold higher from water pipe than from a standard cigarette.14 It is likely, however, that the
true level of HPHC exposure differs from the levels generated by smoking machines
because of differences in use patterns.
Water pipe smoking is a social activity, and typical users are likely to be
exposed to secondhand smoke from the product itself (ie, sidestream smoke), as well
as secondhand smoke exhaled by users (ie, mainstream smoke). The complex patterns of
exposure during typical water pipe smoking sessions remain unclear, but
biomarker-based estimates provide a reasonable assessment of HPHC exposure in water
pipe users. The main HPHCs of cardiovascular concern in water pipe users include
nicotine, particulate matter (PM), CO, volatile organic chemicals, polycyclic
aromatic hydrocarbons (PAHs), acrolein, heavy metals, and arsenic. The comparative
levels of different HPHCs in water pipe emissions versus combustible
cigarettes13,62,63
are shown in Figure 3.
Nicotine
Like cigarette smoke, water pipe smoke is high in nicotine. A
meta-analysis of water pipe users from 4 countries indicates that, on average,
daily use of water pipe tobacco produced a 24-hour urinary cotinine level of
0.783 mg/mL, which is equivalent to smoking 10 cigarettes per day. Even a single
session of water pipe use over a 4-day period delivered the nicotine equivalent
of smoking 2 cigarettes over a 1-day period.64 During a typical isolated water pipe use session in a
clinical research unit, water pipe tobacco smokers had a systemic dose of 2.5 mg
of nicotine, which is equivalent to the dose of smoking 2 to 3
cigarettes.65 In a
naturalistic study of water pipe tobacco smokers in water pipe bars or lounges,
a 73-fold increase in urine nicotine concentration was reported in water pipe
smokers after a single typical session.57 The average plasma nicotine concentration over the
first 24 hours after smoking a full bowl of water pipe tobacco was equivalent to
that after smoking 2 to 3 cigarettes.66
Particulate Matter
Water pipe tobacco smoking generates high levels of PM. The size of the
particles generated in mainstream smoke ranges from 0.01 to 0.2 μm, with
a median diameter of 0.04 to 0.05 μm,62,67 although the
particle size can be as large as 0.15 μm.68 In comparison, cigarette smoke generates
particles between 0.15 and 0.5 μm, with a median particle size of 0.1
pm.62,67 The breathing volume of water pipe smoke
(1 L in this study) was found to contain a greater number of particles
(70×109) than 1 breath (45 mL) of a cigarette
(9.2×109 particles).62 Given that a typical 1-hour session of water pipe
consists of «100 puffs compared with ≈11 puffs of a cigarette, a
single session of water pipe use is likely to lead to at least a 10-fold greater
exposure to tobacco PM. Even after 5 minutes, the number of particles drawn from
a water pipe is twice that generated by a cigarette in a smoking
machine.67
Carbon Monoxide
Water pipes are also a significant source of CO exposure. In
standardized smoking machine protocols, a single water pipe tobacco use session
generates 35 times more CO than a cigarette.67 In addition, side-stream emission of CO during a single
session is estimated to be equivalent to the amount of CO emitted by 10
cigarette smokers in the same space.67 Most of the CO emitted by water pipes seems to be from
charcoal because replacing charcoal with an electric heater decreases CO
emissions by 90%.69 Exposure
estimates from water pipe users show that a single 30- to 90-minute water pipe
smoking session exposes smokers to high levels of CO with exhaled levels between
12 and 60 ppm.65,70–72 The levels of CO in water pipe bar patrons (mean, 30.8
ppm) were much higher than in patrons of traditional bars where cigarette
smoking was permitted (mean, 8.9 ppm).71 The exhaled CO of water pipe smokers after 1 session
(43 ppm) was found to be greater than the amount reported for 1-pack-per-day
cigarette smokers (17 ppm).72
In a laboratory study, CO increased by 24 ppm after 45 minutes of water pipe
smoking and 3 ppm after smoking a single cigarette (a nearly 8-fold greater
abundance in water pipe than cigarette smoke).70 Relative to a single cigarette, a single
session of water pipe use is associated with 3-times-greater blood
carboxyhemoglobin levels, even when peak plasma nicotine levels are
comparable.70 The mean
levels of CO (mean, 6.7 ppm) and PM <2.5 μm (PM2.5;
mean, 264 μg/m3) in water pipe establishments were higher than
the levels of CO (0.4 ppm) and PM2.5 (215 μg/m3) in
a casino where smoking was permitted.73 Exposure to high levels of CO in water pipe smoke could
lead to acute poisoning,74
which includes side effects such as syncope, headache, nausea, or seizure. These
symptoms usually appear when the carboxyhemoglobin levels equal or exceed
17%.75 Several cases
of CO poisoning related to water pipe smoking in young, otherwise healthy adults
have been reported in the literature.75–78
Volatile Organic Compounds
The mainstream tobacco smoke of water pipes contains many of the same
volatile organic chemicals present in cigarette smoke that have been associated
with adverse cardiovascular effects. These include acrolein, benzene, phenols,
and propioaldehyde.72–75 Compared with 1 reference 1R4F
cigarette smoke session, a single water pipe tobacco smoke session (generated
with a standardized smoking machine protocol) produced 27-fold greater levels of
formaldehyde, 4-fold greater acetaldehyde, 19-fold greater acrolein, 9-fold
greater propional-dehyde, and 4-fold greater methacrolein levels.79 Water pipe mainstream tobacco
smoke also contains 6-fold higher benzene (micrograms per session) than
cigarette smoke (micrograms per cigarette).63 The levels of carbonyls in water pipe emissions could
be decreased by increasing the amount of humectants in the unburned tobacco,
which lowers the temperature in the water pipe head.80 Estimates of exposure to typical users,
assessed by measuring the urinary volatile organic chemical metabolites, suggest
that water pipe smokers are exposed to much higher levels of benzene than
cigarette smokers.81 In a
short-term exposure study, the urinary levels of the acrolein metabolite
3-hydroxypropyl mercapturic acid increased 1.4 times after water pipe
smoking.82 Similarly,
urinary levels of S-phenylmercapturic acid, a metabolite of benzene, were
increased 4.2 times after water pipe social events,83 suggesting that water pipe smoking may
be a significant source of both benzene and acrolein exposure.
Polycyclic Aromatic Hydrocarbons
A range of PAHs has been identified in water pipe mainstream tobacco
smoke under standardized machine smoking protocols.14,67,84 The profile
of PAH emissions by water pipes differs from that of cigarettes. Although the
concentration of PAH per 1 mL smoke is lower than in cigarettes, a typical water
pipe smoking session, because of its length, delivers 20 times the total PAH
yields and 50 times the heavy (4- to 5-ring) PAHs. The levels of some PAHs in
water pipe emissions may be 2 to 3 orders of magnitude higher than in cigarette
emissions. Overall, a typical water pipe smoking session can potentially result
in PAH exposure equivalent to 50 cigarettes, in part because of the
significantly larger amount of smoke volume generated during 1 water pipe
session.84 As with CO,
most (50%85 or
75%–92%69) PAHs
emitted in mainstream (exhaled from the user) and sidestream (emitted from the
burning tobacco) water pipe smoke may be derived from charcoal rather than
tobacco and therefore not affected by the presence of nicotine.86 Estimates of exposure to PAHs
by measuring urinary metabolites indicate that water pipe users take in more of
the higher-molecular-weight PAHs such as phenanthrene. In comparison, the intake
of low-molecular-weight PAHs, naphthalene and fluorine is higher during
cigarette smoking.81
Heavy Metals and Arsenic
Multiple heavy metals (Be, Ni, Co, Cr, and Pb) have been detected in
water pipe tobacco smoke.13
As13 and Zn68 have also been detected in
some samples of water pipe smoke. Although the concentrations of As, Be, and Ni
are similar or lower in water pipe condensates, the concentrations of Co, Cr,
and Pb are higher than in commercial cigarettes. The source of the metals is not
clear but may derive from a combination of emissions from tobacco and charcoal.
Different types of raw synthetic and natural charcoals contain heavy metals such
as Zn, Fe, Cd, Vd, Al, Pb, Cr, Mn, and Co, which are at concentrations similar
to or higher than the concentration in cigarette smoke.87
CARDIOVASCULAR EFFECTS OF WATER PIPE SMOKING
Because both mainstream and sidestream water pipe tobacco smoke contains
constituents similar to those generated by cigarettes, the use of water pipes could
similarly lead to short-term cardiovascular changes in addition to long-term
cardiovascular effects. These short-and long-term effects could increase CVD risk
and precipitate cardiovascular events. Although the cardiovascular health effects
and the underlying mechanisms by which water pipe tobacco smoking increases CVD risk
have not been studied to the same extent as those of cigarettes, there are likely
similar. Overlapping mechanisms underlying the effects of both tobacco products
include sympathetic activation, vascular dysfunction, systemic inflammation and
oxidative stress, insulin resistance, enhanced coagulation and thrombosis, and lipid
peroxidation (Figure 4). Additional
constituents specific to water pipe tobacco smoking that are emitted from the
burning charcoal, such as the high levels of CO and benzene, must be considered when
data are extrapolated from cigarette smoking.
Cardiovascular Effects of Short-Term Water Pipe Smoking
As with cigarette smoking, water pipe tobacco smoking leads to an
immediate and transient increase in heart rate and systolic blood pressure. The
extent of these changes varies across studies because of the difference in
exposure conditions, participant demographics, and use patterns. In general, in
young, healthy individuals, smoking tobacco via a water pipe for 15 to 30
minutes increases heart rate by 6 to 13 beats per minute, systolic blood
pressure by 3 to 16 mm Hg,88–91 and
diastolic blood pressure by 2 to 14 mm Hg.88,89,91 These changes are accompanied by a
decrease in heart rate variability91–93 and a
modest increase in coronary blood flow.93 Water pipe tobacco smoking increases myocardial oxygen
demand similar to the effects of cigarette smoking.93 Overall, the short-term cardiovascular
effects are consistent with the sympathomimetic effects of nicotine, which are
mediated by β-adrenergic activation. Indeed, in a double-blind
placebo-controlled study, no changes in heart rate were observed when a
flavor-matched, tobacco-free preparation was smoked.94 Like-wise, the decrease in heart rate
variability with water pipe smoking was prevented by β-adrenergic
blockade.93 Therefore,
the short-term hemodynamic effects of water pipe tobacco smoking may be
attributed to nicotine-induced β-adrenergic stimulation.
In addition to changes in cardiac function and blood flow, water pipe
tobacco smoking has been found to affect vascular function in some,95,96 but not all studies.97 Measurements of vascular function with
plethysmography found that water pipe smoking for 30 minutes immediately
increases vascular resistance and decreases forearm blood flow, venous outflow,
and venous capacitance.96 Both
central and peripheral components are affected immediately after
smoking.95 These
effects are similar to those associated with cigarette smoking and have been
related to attenuated endothelium-dependent vasodilation and hyperactive
neurohormonal response to nicotine exposure or potentially other oxidants in
water pipe smoke, increasing oxidative stress.96 Indeed, although water pipe tobacco
smoking immediately increases the plasma concentration of 8-epi-prostaglandin
F2α (a biomarker for oxidative injury),98 it decreases proinflammatory cytokines,
including interleukin-4, interleukin-5, interleukin-17, and
γ-interferon.97
The short-term hemodynamic effects of water pipe tobacco smoking may
also be related to changes in exercise capacity. The vascular responses to water
pipe smoking are exacerbated among individuals with lower levels of physical
activity or physical fitness.96 In a pilot study of healthy participants, water pipe
tobacco smoking was associated with an impairment of lung function and exercise
capacity. During exercise, after water pipe tobacco smoking, a decrease in
oxygen pulse (from 10.89 to 9.97 mL oxygen per beat) was found, which was also
associated with an increase in the heart rate–oxygen consumption
relationship.90 These
changes may be related to the increase in blood CO levels, which may, in turn,
result in a decrease in the oxygen-carrying capacity of the blood.90
Cardiovascular Effects of Long-Term Water Pipe Smoking
Several studies have reported an association of long-term water pipe use
with increased CVD risk, severity, and mortality.92–94 Most such studies are from the Middle East and
Southeast Asia, where water pipe use is most prevalent. However, the
applicability of these findings to other geographic areas where population
demographics and use patterns differ is uncertain. Moreover, most of these
studies have a small sample size, incomplete exposure assessment, and a lack of
clinical verification of events. Nevertheless, taken together, these data
provide an overall indication of a potential for cardiovascular effects from
long-term water pipe smoking.
In a small cohort of participants with established CVD (documented by
coronary angiography), water pipe smoking has been associated with higher blood
pressure and heart rate. Elevated blood pressure was more pronounced with dual
use (cigarette and water pipe), although exclusive water pipe use was associated
with higher blood pressure than nonsmoking.99 In a population-based study from Syria, daily water
pipe smokers compared with never smokers were found on average to be 2.26
kg/m2 (95% CI, 0.79–3.72; ≈12 lb) heavier, even
after adjustment for cigarette smoking, number of chronic diseases, age, sex,
income, and marital status. They also had nearly 3-fold higher odds of being
obese (odds ratio [OR], 2.87).100 In a study from the Punjab province of Pakistan, long-term
water pipe use was associated with hypertension (OR, 1.95), hyperlipidemia (OR,
1.63), hyperglycemia (OR, 1.82), and abdominal obesity (OR, 1.93) but not with
circulating levels of high-density lipoprotein.101 Age-adjusted prevalence of metabolic
syndrome (identified in accordance with the International Diabetes Federation
definition) was higher among current water pipe smokers than
nonsmokers.101 Taken
together, these findings suggest that the cardiovascular risk profile associated
with long-term water pipe use is similar, but not identical, to that of
cigarette smoking.
A direct comparison of vascular function in cigarette and water pipe
tobacco smokers shows that long-term water pipe users have more severe
decrements in endothelium-dependent, flow-mediated dilation than cigarette
smokers. This difference may be related to the extent of exposure.102 Most water pipe users in the
study smoked 3 to 5 sessions per day, whereas most cigarette smokers smoked 10
to 20 cigarettes per day. Because differences in the frequency of use between
both products could result in higher exposure to HPHCs and nicotine in water
pipe smokers, it seems likely that more severe depression of vascular function
in water pipe smokers may be related to a higher level of exposure, particularly
because there was an inverse correlation between flow-mediated dilation and
smoking duration.102 Although
the mechanisms by which long-term water pipe smoking leads to endothelial
dysfunction remain to be determined, it is speculated that these may be the
result of an underlying chronic inflammatory state. Indeed, there is a
dose-dependent relationship between plasma fibrinogen levels and cigarette and
water pipe smoking. In otherwise healthy men 20 to 75 years of age, the plasma
levels of fibrinogen were elevated markedly in long-term water pipe users
(especially those who smoked for >10 years) compared with
nonsmokers,103
indicating again that CVD risk burden associated with water pipe smoking may be
higher than that associated with cigarette smoking.
There are only limited data to assess the impact of water pipe use
directly on the severity of CVD and associated mortality rates. Nevertheless,
lifetime exposures exceeding 40 water pipe-years (2 water pipes per day for a
total of 20 years or 1 water pipe for 40 years) are associated with a 3-fold
increase in the odds of angio-graphically diagnosed coronary artery
stenosis.104 Coronary
disease, estimated as the mean Duke Jeopardy Score, was much higher in water
pipe smokers than in cigarette smokers or nonsmokers.99 Even those who smoked both cigarettes
and water pipe had a lower score than smokers of water pipe exclusively,
suggesting that water pipe users have a higher burden of atherosclerotic disease
resulting from greater use, greater exposure, or greater toxicity of water pipe
smoke than cigarette smoke. As with cigarette smokers, water pipe smokers have a
higher propensity for ST-segment-elevation myocardial infarction than
nonsmokers, who tend to have non-ST-segment-elevation myocardial infarction
acute coronary syndromes.105
Moreover, water pipe smokers have poorer in-hospital outcomes with higher
mortality, more frequent myocardial ischemia, and higher recurrent myocardial
infarction rates compared with cigarette smokers. In a prospective
population-based study from Iran, heavy water pipe use was associated with a
greater prevalence of heart disease, even when accounting for medication use and
cigarette smoking.106 Fewer
studies have evaluated the association between water pipe smoking and all-cause
and cardiovascular mortality. In 1 study from Bangladesh, water pipe smoking was
associated with higher odds of ischemic heart disease.107 In another study, there was no
association between stroke deaths and water pipe smoking.108 No studies have assessed the
relationship between water pipe and stroke risk, although, on the basis of the
content of the smoke, the risk is anticipated to be at least similar to that of
cigarette smoking. Additional work is warranted to assess the CVD risk burden
associated with water pipe smoking and the risk of all-cause and cardiovascular
mortality in those who smoke water pipes long term.
EFFECTS OF SECONDHAND EXPOSURE TO WATER PIPE TOBACCO SMOKE
As has been found with those exposed to cigarette smoking, individuals
exposed to secondhand water pipe tobacco smoke and residual matter from water pipe
use (ie, third-hand smoke) are at risk for negative health outcomes.6,109 Numerous studies have examined the environmental and
health effects of secondhand exposure to water pipe tobacco smoke in various
geographic regions, including the United States, Canada, the United Kingdom, Russia,
India, and the eastern Mediterranean region.110–115 In
terms of environmental air quality indicators, a primary outcome typically assessed
is the level of PM2.5,116 a known cardiovascular risk agent.117 Although outdoor PM2.5
(originating primarily from fossil fuel combustion) is not directly comparable to PM
generated from water pipes or other tobacco products, PM concentrations are commonly
used to index the presence of secondhand smoke more generally.118
Significantly elevated PM25 levels have been detected in water
pipe cafés/bars or places with high water pipe smoke density (349
μg/m3).110,112,114,119,120 Although PM levels associated with water
pipe smoke vary with the number of individuals smoking, building size/dimensions,
and ventilation characteristics, PM2.5 concentrations of 287,121 400,122 1420,119 and 1 180123 μg/m3 have been reported at different
locations. In each study, the levels of PM2.5 in the bars were higher
than in the ambient air outside the bar, but the levels of PM2.5 were
higher in locations near the water pipe bars, suggesting that PM2.5 from
water pipe bars could elevate PM2.5 levels in the vicinity of these
establishments.121 The
PM25 concentrations reported in many of these studies have been cited
to exceed the air quality guides set by the Environmental Protection Agency (annual
mean, 12 μg/m3; 24-hour average, 35 μg/m3).
Nevertheless, the composition of the tobacco smoke and therefore its health effects
are likely to be quite different from typical ambient air pollution from fossil fuel
combustion, making it difficult to assess the health impact of water pipe emissions
relative to ambient pollution.
In addition to PM, secondhand water pipe smoke contains other potentially
hazardous constituents such as CO, nicotine, tobacco-specific nitrosamines, and
PAHs. Significantly higher levels of ambient CO were observed inside water pipe
bars/restaurants (7.3±2.4 mg/m3) in London, United Kingdom,
relative to levels measured outside these venues (0.9±0.7
μg/m3).121
Results from a study of the home environments of daily water pipe smokers indicated
significantly higher levels of air-based nicotine and surface-based nicotine
compared with nonsmoking homes. In addition, urinary levels of nicotine metabolites
(cotinine), tobacco-specific carcinogenic nitrosamine [nitrosamine
4-(methylnitrosamino)-1-(3-pyridyl)-1-butanol], and acrolein (3-hydroxypropyl
mercapturic acid), a respiratory and cardiovascular toxicant, were significantly
higher among children living in daily water pipe smoking homes, reflecting
secondhand smoke exposure.124
There are few reports of direct health effects associated with secondhand water pipe
smoke exposure. Two studies performed in Lebanon indicated that occupational or
home-based exposure is associated with negative respiratory symptoms (eg, wheezing,
chronic cough).125,126 Taken together, this body of work suggests
that secondhand water pipe smoke may expose individuals, particularly children and
those who work in the water pipe hospitability industry, to several types of water
pipe-associated toxic exposures and potential health risks. Although there are no
specific data detailing the relationship between secondhand water pipe smoke and
chronic disease progression or mortality, similarities to evidence for secondhand
cigarette smoke exposure suggest a similar risk profile.118,127
CESSATION OF WATER PIPE TOBACCO SMOKING
Approximately one-quarter to one-half of water pipe tobacco smokers in the
United States and Middle East want to quit, including youth and young
adults.32 Across several
populations, 25% to 75% of those who want to quit make a quit attempt each
year.128–132 Individuals interested in
quitting are more likely than those not interested in quitting to believe that water
pipe smoking damages health,32,133,134 are less nicotine dependent,130,133,135 are more likely to have received
physician advice to quit,136 and
have family or friends who disapprove its use.130,133,136 In a study from Syria, most water pipe
tobacco smokers who sought cessation treatment smoked at least 6 times per week, had
smoked for several years, and made at least 1 previous unsuccessful quit
attempt.137 The
development of cessation interventions for water pipe tobacco use, both behavioral
and pharmacological, is in its infancy. An expert consensus panel evaluated a wide
range of behavior change techniques deemed to be relevant for supporting water pipe
smokers to quit.138 The panel
achieved moderate to strong agreement on 3 broad categories: preparation and
planning to quit (eg, assessing readiness to quit and previous quit attempts and
facilitating identification of barriers to cessation and problem solving),
increasing awareness of harms of water pipe smoking and advantages of quitting (eg,
providing information on the consequences of smoking and cessation, assessing the
pros and cons of quitting and not quitting), and relapse prevention and sustaining
ex-smoker identity (eg, assessing and providing information on withdrawal symptoms
and facilitating relapse prevention).
Systematic reviews of the impact of cessation interventions for water pipe
smokers identified 5 randomized or cluster-randomized controlled studies that tested
behavioral or pharmacological approaches.139,140 All 5 studies
showed unclear or high risk of bias on key indicators such as blinding and selective
outcome reporting. Two studies showed significantly higher quit rates in the
intervention group. In Pakistan, Dogar and colleagues141 conducted a secondary analysis of a large
cluster-randomized cessation trial that enrolled 1955 patients from 33 health
centers who had suspected pulmonary tuberculosis and smoked water pipe or
cigarettes. Health centers were randomized to provide 1 of 3 treatments: behavioral
support (2 brief consultations that included preparing for the quit day, encouraging
viewing oneself as a nonsmoker, and reviewing progress, consistent with
recommendations by O’Neill et al138), behavioral support plus 7 weeks of treatment with
buproprion, and usual care. Among the 215 water pipe–only smokers, 6-month
quit rates were higher among those who received behavioral support compared with
those who received usual care (45.7% versus 20.3%, respectively; adjusted relative
risk, 2.5 [95% CI, 1.3–4.8]) and among those who received behavioral support
plus buproprion compared with those who received usual care (50.0% versus 20.3%,
respectively; adjusted relative risk, 2.2 [95% CI, 1.3–3.7]). A
community-based cluster trial conducted in Egypt randomized villages to receive a
behavioral intervention consisting of several community health promotion activities
(eg, school prevention efforts, antismoking education in mosques and churches, peer
educators) or no intervention.142
Men in intervention villages who were current water pipe smokers at baseline were
more likely to no longer smoke at 12 months after treatment than men in control
villages (relative risk, 3.3 [95% CI, 1.4–8.9]; calculated by Jawad et
al139).
Three other small randomized trials found positive but nonsignificant
effects of behavioral interventions, including a single-session educational
intervention delivered as a PowerPoint presentation to US college
students,61 a multisession
school-based intervention in Lebanon and Qatar,143 and a multicomponent, physician-delivered, one-on-one
behavioral intervention among Syrian adults.137 Another small trial of 109 US water pipe café
customers who were randomized to a brief, single session of health risk information
and personalized feedback about expired CO levels versus an assessment-only control
found that ≈45% of subjects in both conditions reported no water pipe use at
3 months after treatment.144
Most evaluations of water pipe cessation to date are pilot studies, usually
with only small sample sizes, short follow-up periods, no biochemical verification
of abstinence status, and nonrandomized designs.139 From these studies it appears that certain
behavioral strategies that have proved effective for cigarette cessation may be
useful when adapted for water pipe cessation. These techniques include educating the
smoker about the health consequences of water pipe use, increasing motivation to
quit by reviewing the pros and cons of smoking and quitting, setting and preparing
for the quit day, and providing coping assistance to prevent relapse. Data from
controlled trials are not yet available to determine the efficacy of pharmacological
interventions, but a double-blind randomized controlled trial is underway to test
the efficacy of varenicline for water pipe cessation.145
OVERALL SUMMARY
The data reviewed here support several conclusions:
Water pipe tobacco smoking is prevalent worldwide, especially among
youth and young adults. Most users in Western countries smoke water pipe
intermittently. Many water pipe users concurrently use other forms of
tobacco products.
The spread of water pipe tobacco smoking is promoted by several
factors, including sweetened and flavored water pipe tobacco, social media
that promotes this method of tobacco use, and misperceptions about its
addictive potential and adverse health effects.
A majority of users believe that water pipe tobacco smoking is less
harmful than cigarette smoking, that the probability of addiction is low,
and that quitting water pipe tobacco smoking is not difficult.
The risk of initiation of cigarette smoking may be higher among
water pipe smokers than among never smokers.
The level of nicotine to which water pipe tobacco smokers are
exposed has been demonstrated to be physiologically active in the short
term94 and can
produce dependence with repeated exposure.146
While direct comparisons have some limitations, compared with
smoking a single cigarette, a single session of water pipe smoking typically
results in greater exposure to CO. The CO levels to which water pipe users
are exposed can produce toxicity with short-term exposure at high levels and
interfere with exercise capacity.
The smoking behavior associated with water pipe tobacco
smoking—sessions lasting ≥30 minutes and involving the
inhalation of many liters of smoke—can result in water pipe smokers
inhaling substantial quantities of toxicants during each use
episode.147,148 Water pipe smoke
contains high levels of PM, which contains smaller particles at higher
concentrations than cigarettes. Comparing a single cigarette with a single
water pipe session shows that water pipe use exposes smokers to
significantly higher levels of heavier and more toxic PAHs than cigarette
smoking, as well as cardiorespiratory toxicants such as volatile organic
compounds and heavy metals such as cadmium and lead that can injure the
blood vessels and the brain.
Although evidence for water pipe–attributable disease is not
as robust as the evidence for cigarette smoking, a growing number of studies
suggest that water pipe tobacco smoking is a risk factor for pulmonary
disease and CVD.
KNOWLEDGE GAPS
There are many knowledge gaps on the subject of water pipe tobacco smoking
that provide opportunities for more rigorous studies evaluating the link between
this form of tobacco smoking and a variety of disease outcomes, including CVD and
stroke. Conducting such studies is challenging because the regions where frequent
and long-term water pipe tobacco smoking is most prevalent often lack the resources
required for large-scale epidemiological studies. In addition, the frequency of dual
use of waterpipe and cigarettes can make identifying the specific effects of water
pipe tobacco smoking more difficult. Additional work is needed to test and develop
empirically supported, water pipe–specific cessation interventions. It would
also be beneficial to test both behavioral and pharmacological methods to promote
cessation in adequately powered randomized controlled trials using standardized
outcome criteria, including adequate follow-up durations, biochemical verification
of abstinence, intention-to-treat analysis to maintain prognostic balance when loss
to follow-up occurs, and blinded follow-up assessment.132
Opportunities also exist to address knowledge gaps in communication of the
health effects of water pipe tobacco smoking, cultural influences that may promote
and sustain use across certain population groups, and the development of policies
that can decrease the likelihood of water pipe–induced dependence, disease,
disability, and death among youth worldwide. Currently, there is a persistent
misperception among water pipe users that this method of tobacco use is harmless. In
contrast, many youths are aware of the risks associated with cigarette smoking and
avoid that method of tobacco use because of those risks.
Further research is needed to determine how best to communicate to youth
that the same toxicants that are present in cigarette smoke are present in water
pipe smoke and that any individual who avoids cigarette smoking to avoid inhaling
lethal chemicals should avoid water pipe tobacco smoking for the same reason. This
effort may require a transdisciplinary approach in which health communication
scientists work with other investigators who are familiar with water pipe smoke
toxicant content, user toxicant exposure, and disease risk to craft messages that
are accurate and meaningful to the target audience. The information for such
messaging is available now to inform public health policy, planning, and
practice.
There are also important knowledge gaps in policies that might be most
effective in curtailing the worldwide spread of water pipe tobacco smoking. For
example, although considerable effort has been spent in developing and evaluating
effective policies on cigarette taxation, labeling, advertisement, availability, and
other factors, little policy-related research has addressed water pipe tobacco
smoking. Many of the same policy interventions are likely to be relevant to water
pipe smoking and could be readily adapted to address this form of tobacco use,
although additional innovation may be warranted. For example, because water pipe
tobacco smoking often occurs in dedicated commercial venues where the water pipe
tobacco is handled by staff rather than by user (ie, water pipe bars), these venues
could be taxed (in addition to the tobacco itself). Health warning labeling could be
extended to these venues (eg, required graphic health warning signage in each venue)
and, in addition to tobacco packaging, to the water pipe itself. However,
identification of the characteristics and evaluation of the effectiveness of such
strategies require empirical study.
SUGGESTIONS FOR CLINICAL PRACTICE
To identify and treat water pipe tobacco smokers in clinical settings,
healthcare providers are encouraged to do the following:
Ask users about water pipe use and frequency explicitly, using a
variety of terms if necessary, as well as use of other tobacco products, as
part of routine clinical examinations.
Advise users to quit water pipe and other tobacco product use.
Assist water pipe smokers to quit by providing cessation counseling,
including setting a quit date and providing social support and coping
assistance.
Refer water pipe smokers to credible sources for information on
potential addictiveness and health consequences of water pipe use, including
this statement.
This statement was approved by the American Heart Association Science
Advisory and Coordinating Committee on November 1, 2018, and the American Heart
Association Executive Committee on November 27, 2018. A copy of the document is
available at https://professional.heart.org/statements by using either
“Search for Guidelines & Statements” or the “Browse by
Topic” area. To purchase additional reprints, call 843–216-2533 or
e-mail kelle.ramsay@wolterskluwer.com.
The American Heart Association requests that this document be cited as
follows:
Bhatnagar A, Maziak W, Eissenberg T, Ward KD, Thurston G, King BA, Sutfin
EL, Cobb CO, Griffiths M, Goldstein LB, Rezk-Hanna M; on behalf of the American
Heart Association Behavioral Change for Improving Health Factors Committee of the
Council on Lifestyle and Cardiometabolic Health and Council on Epidemiology and
Prevention; Council on Cardiovascular and Stroke Nursing; Council on Quality of Care
and Outcomes Research; and Stroke Council. Water pipe (hookah) smoking and
cardiovascular disease risk: a scientific statement from the American Heart
Association. Circulation. 2019;139:e917-e936. doi:
10.1161/CIR.0000000000000671.
The expert peer review of AHA-commissioned documents (eg, scientific
statements, clinical practice guidelines, systematic reviews) is conducted by the
AHA Office of Science Operations. For more on AHA statements and guidelines
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Permissions: Multiple copies, modification, alteration, enhancement, and/ or
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Disclaimer: The findings and conclusions in this report are those of the
authors and do not necessarily represent the official position of the US Centers
for Disease Control and Prevention.
The American Heart Association makes every effort to avoid any actual or
potential conflicts of interest that may arise as a result of an outside
relationship or a personal, professional, or business interest of a member of
the writing panel. Specifically, all members of the writing group are required
to complete and submit a Disclosure Questionnaire showing all such relationships
that might be perceived as real or potential conflicts of interest.
Disclosures
Writing Group Disclosures
Writing Group Member
Employment
Research Grant
Other Research
Support
Speakers’
Bureau/Honoraria
Expert Witness
Ownership Interest
Consultant/Advisory
Board
Other
Aruni Bhatnagar
University of Louisville
NIH/FDA (PI)†
None
None
None
None
None
NIH/FDA
(salary[principalinvestigator])†
Caroline O. Cobb
Virginia Commonwealth
University
None
None
None
None
None
None
None
Thomas Eissenberg
Virginia Commonwealth
University
NIH (PI and coinvestigator on
various grants)†
None
None
None
None
None
None
Larry B. Goldstein
University of Kentucky
None
None
None
None
None
None
None
Merlyn Griffiths
University of North
Carolina–Greensboro
NIH (grant $420 830
project)†
None
None
None
None
None
None
Brian A. King
Centers for Disease Control and
Prevention, Office on Smoking and Health
None
None
None
None
None
None
None
Wasim Maziak
Florida International
University
None
None
None
None
None
None
None
Mary Rezk-Hanna
UCLA School of Nursing
None
None
None
None
None
None
None
Erin L. Sutfin
Wake Forest School of Medicine
Social Sciences and Health Policy Medical Center
NIH (PI and coinvestigator on
several NIH-funded grants)†
None
None
None
None
None
None
George Thurston
New York University School of
Medicine
None
None
None
None
None
None
None
Kenneth D. Ward
University of Memphis School of
Public Health
None
None
None
None
None
None
None
This table represents the relationships of writing group
members that may be perceived as actual or reasonably perceived
conflicts of interest as reported on the Disclosure Questionnaire,
which all members of the writing group are required to complete and
submit. A relationship is considered to be
“significant” if
the person receives $10 000 or more during any
12-month period, or 5% or more of the person’s gross income;
or
the person owns 5% or more of the voting stock or share of
the entity or owns $10 000 or more of the fair market value
of the entity. A relationship is considered to be
“modest” if it is less than
“significant” under the preceding definition.
Significant.
Reviewer Disclosures
Reviewer
Employment
Research Grant
Other Research
Support
Speakers’
Bureau/Honoraria
Expert Witness
Ownership Interest
Consultant/Advisory
Board
Other
Neal L. Benowitz
University of California, San
Francisco
NIH†; Flight Attendant
Medical Research Institute†; California Tobacco Related Disease
Research Program†
None
None
None
None
Pfizer*
None
Debabrata Mukherjee
Texas Tech University
None
None
None
None
None
None
None
Mariann R. Piano
Vanderbilt University
None
None
None
None
None
None
None
This table represents the relationships of reviewers that
may be perceived as actual or reasonably perceived conflicts of
interest as reported on the Disclosure Questionnaire, which all
reviewers are required to complete and submit. A relationship is
considered to be “significant” if
the person receives $10,000 or more during any 12-month
period, or 5% or more of the person’s gross income; or
the person owns 5% or more of the voting stock or share of
the entity, or owns $10,000 or more of the fair market value of the
entity. A relationship is considered to be “modest” if
it is less than “significant” under the preceding
definition.
Modest.
Significant.
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