Use & Misuse of Water-filtered Tobacco Smoking Pipes in the World. Consequences for Public Health, Research & Research Ethics.

BACKGROUND: The traditional definition of an "epidemic" has been revisited by antismoking researchers. After 400 years, Doctors would have realized that one aspect of an ancient cultural daily practice of Asian and African societies was in fact a "global "epidemic"". This needed further investigation particularly if one keeps in his mind the health aspects surrounding barbecues. METHOD: Here, up-to-date biomedical results are dialectically confronted with anthropological findings, hence in real life, in order to highlight the extent of the global confusion: from the new definition of an "epidemic" and "prevalence" to the myth of "nicotine "addiction"" and other themes in relation to water filtered tobacco smoking pipes (WFTSPs). RESULTS: We found that over the last decade, many publications, -particularly reviews, "meta-analyses" and "systematic reviews"- on (WFTSPs), have actually contributed to fuelling the greatest mix-up ever witnessed in biomedical research. One main reason for such a situation has been the absolute lack of critical analysis of the available literature and the uncritical use of citations (one seriously flawed review has been cited up to 200 times). Another main reason has been to take as granted a biased smoking robot designed at the US American of Beirut whose measured yields of toxic chemicals may differ dozens of times from others' based on the same "protocol". We also found that, for more than one decade, two other main methodological problems are: 1) the long-lived unwillingness to distinguish between use and misuse; 2) the consistent unethical rejection of biomedical negative results which, interestingly, are quantitatively and qualitatively much more instructive than the positive ones. CONCLUSION: the great majority of WFTSP toxicity studies have actually measured, voluntarily or not, their misuse aspects, not the use in itself. This is in contradiction with both the harm reduction and public health doctrines. The publication of negative results should be encouraged instead of being stifled.

Polonium and lung cancer.

The alpha-radioactive polonium 210 (Po-210) is one of the most powerful carcinogenic agents of tobacco smoke and is responsible for the histotype shift of lung cancer from squamous cell type to adenocarcinoma. According to several studies, the principal source of Po-210 is the fertilizers used in tobacco plants, which are rich in polyphosphates containing radio (Ra-226) and its decay products, lead 210 (Pb-210) and Po-210. Tobacco leaves accumulate Pb-210 and Po-210 through their trichomes, and Pb-210 decays into Po-210 over time. With the combustion of the cigarette smoke becomes radioactive and Pb-210 and Po-210 reach the bronchopulmonary apparatus, especially in bifurcations of segmental bronchi. In this place, combined with other agents, it will manifest its carcinogenic activity, especially in patients with compromised mucous-ciliary clearance. Various studies have confirmed that the radiological risk from Po-210 in a smoker of 20 cigarettes per day for a year is equivalent to the one deriving from 300 chest X-rays, with an autonomous oncogenic capability of 4 lung cancers per 10000 smokers. Po-210 can also be found in passive smoke, since part of Po-210 spreads in the surrounding environment during tobacco combustion. Tobacco manufacturers have been aware of the alpha-radioactivity presence in tobacco smoke since the sixties.

Assessment of narghile (shisha, hookah) smokers' actual exposure to toxic chemicals requires further sound studies.

Tobacco smoking is hazardous for health. However, not all forms of tobacco use entail the same risks and the latter should be studied and compared in a sound realistic way. Smoking machines for cigarettes (which are consumed in a few minutes) were early designed as a tool to evaluate the actual intake of toxic substances ('toxicants') by smokers. However, the yields (tar, nicotine, CO, etc.) provided by such machines poorly reflect the actual human smoking behaviour known to depend on numerous factors (anxiety, emotions, anthropological situation, etc.). In the case of narghile smoking, the problems are even more complex, particularly because of the much longer duration of a session. A recent study from the US-American University of Beirut was based on a field smoking topography and claimed consistency with a laboratory smoking machine. We offer a point by point critical analysis of such methods on which most of the 'waterpipe' antismoking literature since 2002 is based.

A critique of recent hypotheses on oral (and lung) cancer induced by water pipe (hookah, shisha, narghile) tobacco smoking.

The medical hypothesis that the mainstream smoke (the one inhaled by the user) from "water pipes" (mainly: shisha, hookah, narghile) causes oral cancer is certainly acceptable. However, most of the recent reviews on this issue, including an attempt to develop an hypothesis for hookah carcinogenesis, have not cited key references of the world available literature which, so far, generally do not support such an hypothesis. Besides, the proposal is biased since it is apparently an adaptation of the cigarette model whereas cigarette and hookah smokes are, chemically to start with, completely different. Furthermore, all water pipes, despite their striking varieties and the consequences on the chemical processes, are, according to the same cancer-hypothesis, considered as one. The reason is the use, in the cited mainstream literature, of a nominalism ("waterpipe", often in one word) which does not allow any distinction between devices. This critical article suggests to take into account all the peculiar characteristics into consideration in order to come up with another (or several other) carcinogenesis model(s). "Firmly believ[ing] that water pipe smoking can provoke lung cancer as well as oral cancer", based on what may be seen as a rather reductionist view of the issue, is not enough.

Hookah (Shisha, Narghile) Smoking and Environmental Tobacco Smoke (ETS). A critical review of the relevant literature and the public health consequences.

Hookah (narghile, shisha, "water-pipe") smoking is now seen by public health officials as a global tobacco epidemic. Cigarette Environmental Tobacco Smoke (ETS) is classically understood as a combination of Side-Stream Smoke (SSS) and Exhaled Main-Stream Smoke (EMSS), both diluted and aged. Some of the corresponding cigarette studies have served as the scientific basis for stringent legislation on indoor smoking across the world. Interestingly, one of the distinctive traits of the hookah device is that it generates almost no SSS. Indeed, its ETS is made up almost exclusively by the smoke exhaled by the smoker (EMSS), i.e. which has been filtered by the hookah at the level of the bowl, inside the water, along the hose and then by the smoker's respiratory tract itself. The present paper reviews the sparse and scattered scientific evidence available about hookah EMSS and the corresponding inferences that can be drawn from the composition of cigarette EMSS. The reviewed literature shows that most of hookah ETS is made up of EMSS and that the latter qualitatively differs from MSS. Keeping in mind that the first victim of passive smoking is the active smoker her/himself, the toxicity of hookah ETS for non-smokers should not be overestimated and hyped in an unscientific way.