Mes Droits: Tobacco Smoking: an Emerging Health Crisis in the USA

A Critique of “Waterpipe Tobacco Smoking: an Emerging Health Crisis in the United States”

Errors, biases, lies and tricks in connection with: “realistic” smoking; tar and its mysterious composition; nicotine-addiction; carbon monoxide; radioactivity; cancer; environmental tobacco smoke; gateway hypothesis; origins; publication bias; xenophobic bias; biomedical neo-orientalism; etc. [a provisional first draft]

Contents

 Introduction

 Lies…

 “REALISTIC” puff parameters”…

 Nicotine and “nicotine-addiction”

 The Tar Fraud and the Unnecessary CO Scare

 Radioactivity and Cancer issues. Downplaying important unexpected findings by independent researchers

 Gateway Hypothesis

 Environmental Tobacco Smoke

 Origins of the hookah and the “modern” antismoking “concept” of “denialism”

 Xenophobic Bias

Introduction

This new “review” [1] sounds as serious, pressing and useful as similar papers on the “behavioral ecology of secondhand smoke exposure”[2] or the “assessment of tobacco use after hurricane Katrina” [3]. It appears that an important element of the “health crisis” caused by hurricane Katrina would be that some victims could have resumed tobacco smoking… This important study was actually led by Kenneth Ward, one of the co-authors of the ““waterpipe”” article that will be discussed right now [1].

The errors (calculated errors, should we add) are so numerous in this new “review” that only a few selected ones will be scanned below. Indeed, it would be an “epistemic nightmare” to try to discuss all the false claims it contains [4]. This is a salient trait of the antismoking literature in general. This new health scare is also similar to that about the so-called “swine flu” “pandemic” [5]. As expected, the paper is highly politicised (prohibitionist agenda) and stained with numerous biases, including a neo-orientalist vision of science and public health policy. From a conflict-of-interest perspective, the new “review” depicts hookah smoke as not very different from cigarette smoke and heavily insists on the “myth” that hookah would be less harmful than other forms of smoking, thus leading to cigarette use. Obviously, as in the case of the vaccine against the “swine flu”,[5] the undeclared objective could be understood as that of pushing hookah users into the hands of the pharmaceutical industry (for "relevant" treatment with nicotine patches, gums, Zyban, Chantix, etc.) or into those of the tobacco industry which would theoretically end up with the same outcome since both industries, at least since a recent date, seem to have concluded a de facto alliance to share the world nicotine market.

In this new “review”, the four world ““waterpipe”” experts (Thomas Eissenberg, Alan Shihadeh, Wasim Maziak, Kenneth Ward) offer to the world a selfless disinterested harvest of “high standard” updated “science” under a figurehead named Caroline Cobb. Perhaps it is important, from the onset, to stress that these individuals are the very authors of the WHO flawed report [6]. Their article is actually an updated remake of this famous document which itself relied on the most confusionist “review” of the world in this field of research [7]. It should also be noted that, two years ago, the WHO flawed report was recycled and “updated” in the form of a not less erroneous Cochrane Review [8].

Amazingly, the health crisis is depicted as being limited to the USA, not Syria or Lebanon, in spite of the presence, among the authors, of two major

““waterpipe”” US-Middle East experts : Wasim Maziak from the US (funded)-Syrian Centre for Tobacco Studies and his colleague Alan Shihadeh from the US (NCI funded)-American University of Beirut. The public may now be familiar to this kind of “geographical” paradox whereby two non-British ““waterpipe”” experts were assigned a major role in the destruction of civil liberties and economic survival of people in the United Kingdom [9]. In a politicised (prohibition agenda in the UK) interview with ASH (Action on Smoking Health), Alan Shihadeh pedantically explained that colonialism (understood as European colonialism, not US) was one of the reasons of the ““waterpipe”” catastrophe ("heath crisis" could we say now) while Wasim Maziak, not less seriously, ventured into high-level sociological speculations [10]…

Here they are, again, apparently highly concerned with the health of US citizens threatened by the invasion of a not so innocent Middle Eastern object…

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[1] Cobb C, Ward KD, Maziak W, Shihadeh AL, Eissenberg T. Waterpipe tobacco smoking: an emerging health crisis in the United States. Am J Health Behav. 2010 May-Jun;34(3):275-85.

http://www.ncbi.nlm.nih.gov/pubmed/20001185

[2] Hovell MF, Hughes SC. The behavioral ecology of secondhand smoke exposure: A pathway to complete tobacco control. Nicotine & Tobacco Research Advance Access published on September 23, 2009. Nicotine Tob Res 2009 ; 11: 1254-64.

http://dx.doi.org/10.1093/ntr/ntp133

[3] Ken Ward, Shelly Stockton, Fawaz Mzayek, George Relyea Population Based Assessment of Tobacco Use After Hurricane Katrina. University of Memphis 2009.

http://www.memphis.edu/cch/research.php

http://www.drugabuse.gov/whatsnew/meetings/Katrina/index.html

[4] Phillips CV. Debunking the claim that abstinence is usually healthier for smokers than switching to a low-risk alternative, and other observations about anti-tobacco-harm-reduction arguments. Harm Reduction Journal 2009, 6:29 (3 Nov)

http://www.harmreductionjournal.com/content/6/1/29

[5] Girard M. L’art de créer des alertes en santé publique (L’exemple de la grippe porcine. Comment affoler les foules sous des prétextes de santé publique)[The art of designing public health alerts (The example of swine flu. How to scare crowds]. 24 mai 2009.

http://www.rolandsimion.org/spip.php?article33

[6] Chaouachi K. A Critique of the WHO's TobReg "Advisory Note" entitled: "Waterpipe Tobacco Smoking: Health Effects, Research Needs and Recommended Actions by Regulators. Journal of Negative Results in Biomedicine 2006 (17 Nov); 5:17. doi:10.1186/1477-5751-5-17

http://www.jnrbm.com/content/5/1/17

[7] Maziak W, Ward KD, Afifi Soweid RA, Eissenberg T. Tobacco smoking using a waterpipe: a re-emerging strain in a global epidemic. Tobacco Control 2004; 13: 327-333.

http://tobaccocontrol.bmj.com/content/vol13/issue4/

[8] Maziak W, Ward K, Eissenberg T. Interventions for waterpipe smoking cessation. Cochrane Database Syst Rev. 2007 Oct 17;(4):CD005549.

[9] Chaouachi K. [E-Letter] UK Ban on Smoking in General and on Hookah Smoking in Particular Should Not Stay. British Medical Journal 2009 (18 Mar)

http://bmj.com/cgi/eletters/335/7609/20#210647

[10] ASH (Action on Smoking and Health). ““Shisha 200 times worse than a cigarette” say Middle East experts””. 27 March 2007 (prepared by Martin Dockrell)(accessed 13 June, 2008) [based, among others, on an interview with Wasim Maziak and Alan Shihadeh]

Sub-heading: “Three leading experts from across the Middle East have warned that excluding “shisha bars” when England goes smokefree on July 1 could worsen the grave inequalities in health that already affect ethnic minorities.”

http://www.newash.org.uk/ash_4q8eg0ft.htm

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Lies…

1. Lie concerning the relevance of the ““waterpipe”” nominalism. Cobb and the four ““waterpipe”” experts state that "although known by many different names(eg, hookah, narghile, shisha), the term waterpipe has been used for the last 2 decades in the English language scientific literature to refer to any of a variety of instruments that involve passing tobacco smoke through water before inhalation".

This is a lie (sorry, but there is no other word) as huge in size as the recent statement by one of the co-authors (Wasim Maziak) in the Detroit News that research on this topic began only in 2002, i.e. the inception of his US-funded ““waterpipe”” antismoking centre [1][2]. Among the dozens of existing quality independent (from both the pharmaceutical and the tobacco industries) studies in which, most of the time, the main words “shisha”, “hookah”, “narghile” and “goza” have been used, Cobb et al could not find but two publications in Egypt using ““waterpipe”” (in one word)[3][4]. One led in China is also cited although Cobb et al do not point out that in a complementary study, two years later, the same authors split the word in two (“water-pipe” in two words)[5][6]…

In any case, the researchers of the Egyptian and Chinese studies used this word to describe the local pipes they found there. For instance, Lubin et al applied the term to the famous long-stemmed and bamboo pipes. These independent scientists never claimed (nor was it their final objective) that the findings of their studies on these pipes would apply to the world as a whole. For this reason, they could not be considered as nominalists. The nominalists, i.e. the four ““waterpipe”” experts , have, in contrast, and despite early documented warnings, actually fuelled a world confusion in this field. The obvious objective was –and still is- to let lay people (i.e. the general public who reads the daily US press in which the same experts or their friends of the antismoking movement, are systematically and univocally interviewed) believe that all pipes in which there is water induce the same health effects. Since the chemistry of smoke is different in each case [2], this represents, once again, a serious case of scientific misconduct for which they will be accountable.

Interestingly, the cited Egyptian and Chinese studies were, respectively, about bladder and lung cancer. For years, the ““waterpipe”” experts have cited these two studies to support their claim in antismoking journals (Tobacco Control, Nicotine and Tobacco Research, etc.) that shisha causes bladder and lung cancer, i.e. the opposite of the conclusions reached by the authors of these studies [2].

2. Lie about temperatures of tobacco. After half a decade of ““waterpipe”” publications stating that “tobacco is burnt” in a ““waterpipe””, the experts were led to correct their vocabulary and use the word “heat” instead of “burn”... However, Cobb et al paper downplays the importance of the very low temperatures to which the tobacco-molasses mixture is subjected to in a hookah bowl. More, they go so far as stating that tobacco is heated at 450°C which is NOT the temperature of the smoking mixture but that of the burning charcoal. That of the former easily reaches 200°C below that figure… This error, or this lie to be more accurate, is in fact not that innocent.

3. Lie about the nature of their so-called “review” of the existing literature.The authors claim that they have performed “a literature review” whereas they have carefully selected the papers which correspond to their final goal : eradication, prohibition. When the results of some unavoidable studies were hazardous for their agenda, only partial data have been picked out (case of the first aetiological study on hookah smoking and cancer by Sajid et al.).

It is also noteworthy that about 10 articles from the US daily popular press were cited in their bibliography…. Besides, these papers are well known for voicing only one scientific side (the antismoking one) with, most of the time, systematic interviews with the four ““waterpipe”” experts or their colleagues (parroting their "findings").

4. Lie which almost qualifies for plagiarism. Plagiarism is a common plague, including that performed by national antismoking top experts [7]. Cobb et al state that "the spread of waterpipe tobacco smoking may be attributable, at least in part, to the ready commercial availability of flavored tobacco and quicklighting charcoal" and cite the Cochrane Review (i.e., the erroneous recycled version of the WHO flawed report) to support this idea. While these experts have always focussed on the flavoured tobacco as the main explanation, they have “borrowed” the other factor (quick-lighting charcoal) from well-known sources. See, for instance, the table of the 15 reasons published elsewhere in the peer-reviewed literature [8].

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[1] Kozlowski, Kim. Michigan health leaders target growing hookah use. The Detroit News 2009 (Friday, Aug 14)

http://detnews.com/article/20090814/LIFESTYLE03/908140351/1409/METRO/Mich.-health-leaders-target-growing-hookah-use

[2] Chaouachi K, Sajid KM. A critique of recent hypotheses on oral (and lung) cancer induced by water pipe (hookah, shisha, narghile) tobacco smoking. Med Hypotheses 2009 (online: 24 Dec). doi:10.1016/j.mehy.2009.11.036

http://dx.doi.org/10.1016/j.mehy.2009.11.036

[3] Inhorn MC, Buss KA. Ethnography, epidemiology and infertility in Egypt. Soc Sci Med. 1994;39(5):671-686.

[4] Bedwani R, El-Khwsky F, Renganathan E, Braga C, Abu Seif HH, Abul Azm T, Zaki A, Franceschi S, Boffetta P, La Vecchia C. Epidemiology of bladder cancer in Alexandria, Egypt: tobacco smoking. Int J Cancer. 1997 Sep 26;73(1):64-7.

[5] Lubin JH, Qiao YL, Taylor PR, Yao SX, Schatzkin A, Mao BL, Rao JY, Xuan XZ, Li JY. Quantitative evaluation of the radon and lung cancer association in a case control study of Chinese tin miners. Cancer Res. 1990 Jan 1;50(1):174-80.

[6] Lubin JH, Li JY, Xuan XZ, Cai SK, Luo, Yang QS, Wang JZ, Yang L; Blot WJ. Risk of lung cancer among cigarette and pipe smokers in southern China. Int. J. of Cancer 1992 (28 May); 51 (3)3: 390-5.

[7] Chaouachi K. An Open Letter against Plagiarism and Plagiarists. Tabaccologia 2009; 1: 46-7 [English version]

http://www.tabaccologia.org/PDF/1_2009/19_1_2009.pdf

[8] Chaouachi K. Hookah (Shisha, Narghile) Smoking and Environmental Tobacco Smoke (ETS). A Critical Review of the Relevant Literature and the Public Health Consequences. Int. J. Environ. Res. Public Health 2009; 6(2):798-843.

http://www.pubmedcentral.nih.gov/articlerender.fcgi?tool=pubmed&pubmedid=19440416

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“REALISTIC” puff parameters”…

In a printed table, Cobb et al announces figures for CO, nicotine and tar, supposedly obtained through the use of a “realistic” (sic) smoking machine. Of course it is not. The methodology has been criticised in detail in several peer-reviewed journals, so it would be tedious to go back again into these details [1]. Repeating is a characteristic of antismoking propaganda [2]. The main trick has been exposed. May the reader have a look at the inter-puff interval : around 15 s; that is the time between two puffs for a full hour with the charcoal in the same position atop the bowl. What a small handful of scientist have noticed so far is that making an average of this human behaviour (smoking) is mathematically and epistemologically unacceptable because of numerous contingencies. Think of a simple cigarette whose duration is only 5 minutes or so and whose model corresponding smoking machine draws a puff each minute, i.e. each 60s. This represents a pace 4 times slower pace for a duration of up to 10 times less. Yet, the model of the cigarette smoking has given birth to scientific debates and most tobacco experts consider it as failing to reflect the complex reality of human smoking. In these conditions, what is seen criticised when it comes to the “Western” cigarette is accepted for the “Eastern” narghile… This is a striking double-standard for which those teams are already accountable because of the huge confusion they have fuelled in the world. Consequently, it would be vain to discuss too much the high figures, obtained though this means, for tar and particularly, polycyclic aromatic hydrocarbons.

The opportunity is taken here to point out that another technique for scaring people, and parents in particular, is to present figures (levels of toxic substances for instances in a particular way. For instance, instead of writing “90 litres of smoke”, the ““waterpipe”” experts would rather say something like: "a single waterpipe use episode [is] about90,000 ml of smoke”…

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[1] Chaouachi K. Public health intervention for narghile (hookah, shisha) use requires a radical critique of the related “standardised” smoking machine. Journal of Public Health [Springer Berlin/Heidelberg] 2009; 17(5): 355-9. DOI : 10.1007/s10389-009-0272-7

http://www.springerlink.com/content/58352477706011t0/

[2] Chaouachi K. An Anthology of Serious though Widespread Errors in the ““Waterpipe”” (Hookah, Shisha, Narghile) Mainstream Biomedical Literature:Tobacco is Dangerous. However, parroting in this field of research has been detrimental to public health. Knol 2009 (18 Oct).

http://knol.google.com/k/kamal-chaouachi/an-anthology-of-serious-though/534k6mvefph/6

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Nicotine and “nicotine-addiction”

In another antismoking journal of the same family, two co-authors (Thomas Eissenberg and Alan Shihadeh), have recently published a study on real human smokers. Not only it was not the first study as they pompously stated (Egyptian studies have been carried out long before year 2009) but they could not find in the blood of a shisha smoker sitting for a 45 min session more nicotine than in blood of a cigarette smoker having smoked a single cigarette [1]… It is clear that it is going to be difficult to get addicted-to-nicotine this way…. Indeed, does 1 hookah equals 100 or 200 cigarettes as the same ““waterpipe”” experts have been claiming in the past [2]? Cobb et al also cite a “meta-analysis of studies looking at waterpipe users’ exposure to the psychoactive and dependence-producing drug nicotine”[3]. This article would show that “daily waterpipe use produces a urinary cotinine level that corresponds to a nicotine absorption rate equal to smoking 10 cigarettes per day". This “meta-analysis” has absolutely no scientific value as it actually compared “oranges with apples” as emphasised in a recent peer-reviewed publication [4].

Interestingly, the findings of the above mentioned human experiment highlight the fraud of the US-American University of Beirut smoking machine supposed to “realistically” model the behaviour of a hookah smoker. Eissenberg and Shihadeh found (in real human smokers) an average inter-puff time of 43s, i.e. almost 3 times larger than the supposedly “realistic” parameter used so far (17s) and supposed to be based on a not less “realistic” “smoking topography” [5].

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[1] Eissenberg T, Shihadeh A. Waterpipe tobacco and cigarette smoking direct comparison of toxicant exposure. Am J Prev Med. 2009 Dec;37(6):518-23.

http://www.ajpm-online.net/article/S0749-3797%2809%2900583-2/abstract

[2] ASH (Action on Smoking and Health). ““Shisha 200 times worse than a cigarette” say Middle East experts””. 27 March 2007 (prepared by Martin Dockrell)(accessed 13 June, 2008) [based, among others, on an interview with Wasim Maziak and Alan Shihadeh]

http://www.newash.org.uk/ash_4q8eg0ft.htm

[3] Neergaard J, Singh P, Job J, Montgomery S. Waterpipe smoking and nicotine exposure: A review of the current evidence. Nicotine Tob Res. 2007 Oct;9(10):987-94.

[4] Chaouachi K, Sajid KM. A critique of recent hypotheses on oral (and lung) cancer induced by water pipe (hookah, shisha, narghile) tobacco smoking. Med Hypotheses 2009 (online: 24 Dec). doi:10.1016/j.mehy.2009.11.036

http://dx.doi.org/10.1016/j.mehy.2009.11.036

[5] Chaouachi K. Public health intervention for narghile (hookah, shisha) use requires a radical critique of the related “standardised” smoking machine. Journal of Public Health [Springer Berlin/Heidelberg] 2009; 17(5): 355-9. DOI : 10.1007/s10389-009-0272-7

http://www.springerlink.com/content/58352477706011t0/

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The Tar Fraud and the Unnecessary CO Scare

Table 2 looks like a rectangle on a cigarette pack… It is entitled:"Machine-generated Smoke Content Using Realistic Puff Parameters for a Single Waterpipe Episode and a Single Cigarette"

1. First aspect of the fraud. Glycerol is a major component of tar. What few people know, including many researchers, is that the proportion of the former is actually included in the tar yield figure. So, when antismoking brandish an artificially obtained tar yield of 802 mg, free citizens are entitled to ask them, not only to stress that cigarette tar and hookah tar are quantitatively and qualitatively completely different from each other, but, also, concerning the latter aspect, that 40% of the tar is made up of glycerol, a biologically inactive substance [1]. Also, what ““waterpipe”” researchers never say is that hookah smoke is also made up of water in a similar proportion as glycerol. In these conditions, water and glycerol are the main components of hookah smoke (when used with moassel). In spite of this prevalent unscientific blackout, this important point was published in peer-reviewed journals [1].

2. Second aspect of the fraud. The “smoking machine” was absolutely not “realistic”. It has been criticised in peer-reviewed journals for its numerous biases: unrealistic set-up and not less unrealistic puffing parameters [2].

3. Third aspect of the fraud. The hookah and cigarette yields (i.e. the figures in the table) were obtained through the use of two completely different smoking machines [2].

4. Fourth aspect of the fraud. Averaging the smoking behaviour has been performed for only 5 minutes in the case of cigarettes. In the case of hookah, the events occurring during a full hour (60 min) session have been averaged. This is mathematically and epistemologically unacceptable [1].

Concerning Carbon Monoxide (CO) supposed to be “6.5 times” the [cigarette] CO”, hookah users and non-users may have already understood the underlying tricky propaganda. ““Waterpipe”” actually experts deceive the general public by crudely comparing chronic CO intake (as cigarette use implies) with sporadic absorption (one or several times a day). Indeed, another fact that is systematically hidden by antismokers is that, fortunately for hookah users, the half-life of CO is very short. This means that this dangerous gas is relatively quickly flushed out of the body. Since the BBC unethical scare of last Autumn, the general public seems more and more mature regarding this topic [3][4].

To close this chapter, Cobb et al cite a US study about CO without noting a striking conflict of interest on behalf of the co-author, Katharine Hammond [5]. On the one hand, the latter is a member of WHO TobReg, the group of experts who have “peer-reviewed” and validated the WHO flawed report [6]. On the other, the co-author should have disclosed that she actually is an “Exposure Assessment Research investigator” for the UCSF FAMRI Center because FAMRI officially funds research on diseases caused by ETS (Environmental Tobacco Smoke). Such an affiliation has obviously influenced the paper that she not only supervised but also co-authored, particularly the concluding sentence: “the high levels of exhaled CO found in this study indicate a possibly significant health hazard from use of waterpipes that requires further study"[7].

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[1] Chaouachi K, Sajid KM. A critique of recent hypotheses on oral (and lung) cancer induced by water pipe (hookah, shisha, narghile) tobacco smoking. Med Hypotheses 2009 (online: 24 Dec). doi:10.1016/j.mehy.2009.11.036

http://dx.doi.org/10.1016/j.mehy.2009.11.036

[2] Chaouachi K. Public health intervention for narghile (hookah, shisha) use requires a radical critique of the related “standardised” smoking machine. Journal of Public Health [Springer Berlin/Heidelberg] 2009; 17(5): 355-9. DOI : 10.1007/s10389-009-0272-7

http://www.springerlink.com/content/58352477706011t0/

[3] Snowdon, Chris. Shisha Madness: BBC and Department of Health accused of "gross exaggeration" in shisha story. 25 Aug 2009.

www.pr-inside.com/bbc-accused-of-gross-exaggeration-in-r1453218.htm

[4] Hayes, Patrick. Big trouble in ‘Little Cairo’. Spiked online 2009 (3 Sep)

http://www.spiked-online.com/index.php/site/article/7338/

[5] El-Nachef WN, Hammond SK. Exhaled carbon monoxide with waterpipe use in US students. JAMA 2008 (Jan 2);299(1):36-8.

http://www.jnrbm.com/content/5/1/17

[7] FAMRI Bland Lane Center of Excellence on Second Hand Smoke at UCSF: “supported by the National Flight Attendant Medical Research Institute (FAMRI) program. FAMRI is funded through a settlement from a class action lawsuit against tobacco companies on behalf of flight attendants who sustained health problems due to exposure to second hand smoke in their job”.

http://tobacco.ucsf.edu/index.cfm?ucsfaction=famricenter.main

FAMRI: http://www.famri.org/researchers/awards_history.html

http://www.famri.org/about_famri/mission_statement.html

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Radioactivity and Cancer issues. Downplaying important unexpected findings by independent researchers

In a pathetic way, Cobb et al insist on Polonium 210 levels. The reader is invited to avoid their distorting looking glass and access the very source : a study published in the Journal of Environmental Radioactivity [1]. As for cancer, Cobb et al cite the first aetiological studies on hookah smoking and cancer [2], unfortunately not to tell the whole truth about their scope and consequences. Instead, they focus on a “cherry-picked” element of the study : levels of a cancer marker (CEA) in heavy smokers (who, by the way, do not exist in the USA…) only.

First, they do not reveal that the hookah smokers (rigorously selected exclusive hookah users in remote villages of the Punjabi countryside) have been using, for decades and in several daily sessions, large amounts of tobacco; the weight equivalent of up to 60 cigarettes in the bowl). Globally taken and bearing in mind the last detail about the quantity of tobacco, the mean levels of the cancer marker (though varying between so-called “light” smokers and “heavy” smokers) appeared to be much lower than those reported among cigarette smokers.

This important information is swept under the carpet by Cobb et al. They focus only on the levels measured in heavy smokers (whose average levels of the cancer marker did not even reach those of cigarette smokers), brushing aside medium smokers and light smokers (by the way, more akin to the US smokers). They even fail to describe what was a heavy smoker in that study: in fact, a smoker who spends up to six hours each day smoking the above-recalled high amounts of tobacco… In sum, the lesson of these findings for any half normal individual is that the poison makes the dose. As brilliant epidemiologists, one of the ““waterpipe”” experts being a world-known “visionary” lesson-giver [3][4], Cobb et al feign to ignore these taboo issues.

Dozens of cancer studies led by prestigious independent cancer specialists came up with negative results (therefore, non-politically-correct) showed a weak or no association between cancer and hookah smoking. They are systematically never cited as is they did not exist. Out of dispair, the ““waterpipe”” experts cannot cite but one study, by Nafae et al, that found an association [5]. However, this paper was criticised in a peer-reviewed journal [6].

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[1] Khater AE, Abd El-Aziz NS, Al-Sewaidan HA, Chaouachi K. Radiological hazards of Narghile (hookah, shisha, goza) smoking: activity concentrations and dose assessment. J Environ Radioact. 2008 Dec;99(12):1808-14.

http://dx.doi.org/10.1016/j.jenvrad.2008.07.005

[2] Sajid KM, Chaouachi K, Mahmood R. Hookah smoking and cancer. Carcinoembryonic Antigen (CEA) levels in exclusive/ever hookah smokers. Harm Reduct J 2008 24 May;5(19)

http://www.harmreductionjournal.com/content/5/1/19

[3] Chaouachi K. The Most Beautiful Girl in the World Cannot Give More than What She Has and the History of “Tobacco Control” Will Absolve Me. A rebuttal to Dr MAZIAK’s Comment. Harm Reduction Journal 2008 (8 July)

http://www.harmreductionjournal.com/content/5/1/19/commENTS#305595

[4] Dunn J. A response to the crisis of epidemiology. Forces 2009 (6 Mar)

http://www.forces.org/Scientific_Portal/evidence_viewer.php?id=413

[5] Nafae A, Misra SP, Dhar SN, Shah SN. Bronchogenic carcinoma in Kashmir Valley. Indian J Chest Dis. 1973 Oct; 15(4):285-95.

[6] Chaouachi K. Hookah epidemic [Clarification about Cancer]. Br Dent J 2009; 207: 192-3. DOI: 10.1038/sj.bdj.2009.771

http://www.nature.com/doifinder/10.1038/sj.bdj.2009.771

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Gateway Hypothesis

This hypothesis (switching from hookah to cigarette use) is so irrelevant that Cobb et al article if full of “it may”, “it may”... All soundly and independently led studies in this field actually show, so far, that there is no such thing. Of course, this topic is connected with the “nicotine-addiction” one discussed before. As expected, the ““Waterpipe”” experts omit to mention negative results such as those from an important recent Australian survey involving a large sample. Its authors concluded that they “are not alarmed about potential switching as only one ex-CCP [Cigarette/Cigar/Pipe] smoker (out of 1,102 respondents) also reported smoking WT [Water pipe Tobacco] on a daily basis” [1].

Once again in a pathetic way reflecting the collapse of their scientific world, the ““waterpipe”” cite completely biased papers relying on biased questionnaires -themselves interviewing users of both cigarettes and hookah. The idea is to demonstrate that hookah is “a precursor to cigarette smoking”…

Quotation: “Such a prospect is plausible given that waterpipe tobacco smoking is time-consuming and largely sedentary: active individuals who enjoy the effects of smoking tobacco with a waterpipe may turn to cigarettes for a more convenient and mobile smoking method. Evidence from cross-sectional study of Arab American adolescents shows that the odds of experimenting with cigarettes were 8 times greater for those who have ever smoked tobacco using a waterpipe”[2].

The cited survey by Virginia Rice et al. (from Wayne University, Michigan) was based on questionnaires adapted from “classical” “tobacco questionnaires”(sic) which have been neither validated nor published. Furthermore, the researchers of this university have proved to have absolutely no sound knowledge of tobacco issues. In a video somewhere, on of them states that hookah “tar is burning”…

If the hookah smokers are not “addicted-to-nicotine”, then this is a big problem for a great wing of antismoking activists and researchers. Even when all the bulk of evidence points to the opposite direction (as in the case of lung cancer), this hypothesis needs to be “demonstrated” as “true” because most antismoking studies, particularly anti-““waterpipe”” ones, are financed, directly or indirectly, by the pharmaceutical industry (nicotine “replacement” therapies and tools (nicotine gums, patches); Zyban (bupropion), Chantix (varenicline), etc.). Consequently, it is no surprise to see the ““waterpipe”” experts conclude by a call to “health care providers” who will be tempted to prescribe such drugs to their “patients”.

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[1] Carroll T, Poder N, Perusco A. Is concern about waterpipe tobacco smoking warranted? Aust N Z J Public Health. 2008 Apr;32(2):181-2.

[2] Rice VH, Weglicki LS, Templin T, Hammad A, Jamil H, Kulwicki A. Predictors of Arab American adolescent tobacco use. Merrill-Palmer Quarterly 2006;52: 327-42.

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Environmental Tobacco Smoke

Once again, the hazards of hookah environmental tobacco smoke are hyperbolised by citing a flawed study published in the antismoking Nicotine and Tobacco Research journal: "Exposure to waterpipe-associated toxicants is not restricted to users; nearby nonsmokers may also be exposed. Recent studies show that mainstream smoke from a waterpipe contains high levels of fine particulate matter, which can be an important cardio-respiratory hazard. A considerable proportion of these particles (eg, PM2.5) are emitted by waterpipe tobacco smokers to the surrounding air, reaching levels compared to those associated with cigarette smoking. These data justify inclusion of waterpipe cafés and lounges in current clean indoor air policies aimed at protecting customers and workers of these establishments"[1].

What is even more absurd is that the same cited study found no side-stream smoke in the biased experiment…: "Smoldering [i.e. SIDE-STREAM SMOKE] of waterpipe, however, did not seem to contribute to indoor particulate matter, in sharp contrast to what is witnessed with cigarette smoking, where smoldering can be a substantial source of hazardous PM emissions"[1] .

A clarification and recapitulation of all the pseudo-science (actually Lysenkoist science) surrounding this highly politicised aspects of smoking,[2] has been published in an important article [3].

See further critiques of similar moves by the US-American University of Beirut (Alan Shihadeh, co-author) to support and justify bans on hospitality venues in the United Kingdom [4].

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[1] Maziak W, Rastam S, Ibrahim I, Ward KD, Eissenberg T. Waterpipe-associated particulate matter emissions. Nicotine Tob Res. 2008 Mar;10(3):519-23.

[2] Enstrom JE. Defending legitimate epidemiologic research: combating Lysenko pseudoscience. Epidemiologic Perspectives & Innovations 2007 (10 Oct);4:11

http://www.epi-perspectives.com/content/4/1/11

[3] Chaouachi K. Hookah (Shisha, Narghile) Smoking and Environmental Tobacco Smoke (ETS). A Critical Review of the Relevant Literature and the Public Health Consequences. Int. J. Environ. Res. Public Health 2009; 6(2):798-843.

http://www.pubmedcentral.nih.gov/articlerender.fcgi?tool=pubmed&pubmedid=19440416

[4] Chaouachi K. UK Ban on Smoking in General and on Hookah Smoking in Particular Should Not Stay. British Medical Journal2009 (18 Mar)

http://bmj.com/cgi/eletters/335/7609/20#210647

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Origins of the hookah and the “modern” antismoking “concept” of “denialism”

Since 2002, inception date of the antismoking activities led by US-funded anti-““waterpipe”” centres in Syria and Lebanon, the question of the origins of the hookah (which should be a point of minor interest for biomedical researchers) has been given a disproportionate importance. ““Waterpipe”” experts have found a “convenient” and official date for its “invention”: 1605; year by which an Irani physician working at the Indian court, would have “invented” the contraption, “misbelieving” –according to the antismoking doctrine- that it would render the tobacco smoke less harmful…

However, in retrospect, hookah has undoubtedly represented an actual harm reduction form of smoking over centuries [1]. Consequently, the functionalist objective followed by antismoking researchers is to hammer (including by staining the scientific credibility of biomedical journals) everywhere that the so-called reduced harm is a “myth” as old as its “invention”… Hence, the necessity for them to keep insisting on the anecdote about the physician who wanted to make tobacco smoking less harmful. Of course, the scientific evidence (swept under the carpet by them) points to a much older era and this was clarified in the critique the WHO flawed report whose two first sentences (yes, the two first ones) contain errors in connection with this aspect [2]... Finally, readers who are interested in the “modern” antismoking “concept” of “denialism” may refer to other relevant sources [3].

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[1] Chaouachi K. Harm Reduction Techniques for Hookah (shisha, narghile, “water pipe”) Smoking of Tobacco Based Products. Med Hypotheses 2009 Oct;73(4):623-4.

http://dx.doi.org/10.1016/j.mehy.2009.06.016

[2] Chaouachi K. A Critique of the WHO's TobReg "Advisory Note" entitled: "Waterpipe Tobacco Smoking: Health Effects, Research Needs and Recommended Actions by Regulators. Journal of Negative Results in Biomedicine 2006 (17 Nov); 5:17. doi:10.1186/1477-5751-5-17

http://www.jnrbm.com/content/5/1/17

[3] Diethelm, P, McKee, M. Denialism: what is it and how should scientists respond? Eur J Public Health. 2009; 19:2-4.

http://eurpub.oxfordjournals.org/cgi/eletters/19/1/2#114

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Xenophobic Bias

The ““waterpipe”” experts, as respectable representatives of the world US dominating English-speaking science, state: "Despite the long history of the waterpipe, the health effects of this method of tobacco smoking have not been as clearly documented as for cigarettes, perhaps due to a lack of adequate resources in the world regions where waterpipe tobacco smoking traditionally has occurred. The available evidence, although scant, suggests that waterpipe tobacco smokers, like cigarette smokers, are at risk for nicotine/tobacco dependence, cardiovascular disease, and cancer."

Apparently "innocent", this statement, once put in pespective, proves to be a xenophobic lie and a renewed insult to independent (from both the tobacco and pharmaceutical industries) researchers, particularly in Asia and Africa, who –with modest though quite “adequate” resources-, and over long decades, have published, in peer-reviewed journals, excellent and realistic studies which have set the broad framework of what we know today about hookah smoking and health. Instead of denying their existence in the so-called “peer-reviewed” publications, which is also a high form of contempt, these works should be systematically cited. However, the problem for antismoking researchers is that the authors of these studies found negative results (about lung cancer, addiction, etc.)…

The US ““waterpipe”” experts would like to correct several centuries of misconceptions, not only among hookah users, but also among researchers… Fortunately, they were recently reminded that the grandfather of one of the authors of the first aetiological study on hookah smoking and cancer was a heavy hookah smoker who, however died at the age of 110 [1].

Recently, an independent (from both the pharmaceutical and tobacco industries) African high calibre physiologist has published a two-fold critical comprehensive review of hookah health effects [2][3]. He has particularly highlighted the negative consequences for public health intervention due to the state of international confusion fuelled by the US-““waterpipe”” teams.

The past and modern examples of quality research in Asia and Africa are many. The reason is very simple. These researchers (unlike those who have been brainwashed in US-antismoking funded institutions) have a perfect (social, cultural, etc.) knowledge of their local context. Indeed, these scientists have made the field move forward, not waddle as ““waterpipe”” experts, with their prohibition agenda on mind, have done since 2002 [4][5].

From neo-orientalist conceptions to methodological artefacts

The ““waterpipe”” experts say: "In a study of a convenience sample of 1872 14- to 18-year-olds in the US Midwest, 16.7% Arab American youth, and 11.3% non-Arab youth reported pastmonth waterpipe use. Clearly, cultural factors may be important in understanding waterpipe use among these Arab American populations, and more work addressing this issue is necessary."

The corresponding poor studies were carried out by Virginia Rice’s team at Wayne University (Michigan)[6][7](see also the discussion on the Gateway hypothesis). The prevalence rates among Arab-American were actually published without any critical analysis of the data. Clearly, there was a xenophobic bias because the hookah antismoking campaigns of the last years in the USA have been driven more by hysteria and xenophobia (particularly in the context of the “War on Terror”) than scientific integrity. What is above all a problem for antismoking activists and researchers is that hookah smoking, as a lifestyle, is seen as a scaring “Arab way” of smoking. Certainly, anti-““waterpipe”” researchers have succeeded, thanks to the mass media sound box, in scaring and deterring “non-Arab” US Americans from indulging in hookah smoking. Hence the biased figures. However, they failed with “Arab” US Americans in spite of the violent antismoking campaigns (see raged video reaction by angry hookah smoker)[8]. Because of their socio-cultural roots and better knowledge of the anthropological aspects of hookah smoking, US-Arab Americans have perfectly understood the scheme and the pseudo-science (on hookah addiction, passive smoking, etc.) that too often underpins the permanent “public health” scares targeting their grandfathers’ “art-de-vivre”. This last word was used by a prestigious independent (from both the pharmaceutical and tobacco industries) Lebanese lung specialist [9] .

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http://dx.doi.org/10.1016/j.mehy.2009.11.036

[2] Ben Saad H. Le narguilé et ses effets sur la santé. Partie I : le narguilé, description générale et propriétés [The narghile and its effects on health. Part I: The narghile, general description and properties]. Rev Pneumol Clin 2009 65: 369 [Epub ahead of print 6 Nov]. Doi : 10.1016/j.pneumo.2009.08.010

http://www.ncbi.nlm.nih.gov/pubmed/19995660

[3] Ben Saad H. Le narguilé et ses effets sur la santé. Partie II : les effets du narguilé sur la santé [The narghile and its effects on health. Part II: The effects of the narghile on health]. Rev Pneumol Clin 2009 [Epub ahead of print 6 Nov]. Doi : 10.1016/j.pneumo.2009.08.011

http://www.em-consulte.com/article/231124

[4] Editorial. Shisha Smoking. Arab News Newspaper. The Middle East's Leading English Language Daily 2009 (26 Aug)

http://www.arabnews.com/?page=7&section=0&article=125797&d=26&m=8&y=2009

[5] Chaouachi K. Letter to the Editor. Arab News 2009 (4 Sept).

http://www.arabnews.com/?page=17&section=21&d=4&m=9&y=2009&mode=dynamic&sectionlist=no&pix=interact.jpg&category=Interact

[6] Rice VH, Weglicki LS, Templin T, Hammad A, Jamil H, Kulwicki A. Predictors of Arab American adolescent tobacco use. Merrill-Palmer Quarterly 2006;52: 327-42.

[7] Rice VH, Weglicki LS, Templin T, Jamil H, Hammad A. Intervention effects on tobacco use in Arab and non-Arab American adolescents. Addict Behav. 2010 Jan;35(1):46-8. Epub 2009 Aug 21.

http://www.ncbi.nlm.nih.gov/pubmed/19767152

[8] Video: Rant about Hookah worse the Cigarettes ?

http://www.youtube.com/watch?v=L55-6U_xQww

Note: one comment by “Zombiex69” states: “The tobacco used for a hookah is wet.. there is your smoke volume. As for the new "concerned parent" craze about the subject, there might be a bit of xenophobia involved due to the eastern origin of the hookah. It may have a health risk to it, so moderate your use. But I'm sensing a racist bias toward eastern culture more than a legitimate health concern.”

[9] Waked M. Le Narguilé: quand la fumée se dissipe [Nargile: beyond the cloudy smoke]. La Lettre du Pneumologue [Edimark], 2006 ; 9 (55) : 177-79.

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Conclusion and the Economics of "more research is needed"

This “new” “review” by Cobb and the four world ““waterpipe”” experts is as calamitous as the previous “original” or recycled (although, as the Cochrane one shows, still containing many errors) [1][2]. ““Waterpipe”” experts repeatedly say that "more research is needed” as if their highly (public money) funded dozens of papers on ““waterpipe”” had led to insignificant advances in this field of research [3]... This motto is a actually a kind of code and has fortunately not remained uncommented [4].

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[1] Maziak W, Ward KD, Afifi Soweid RA, Eissenberg T. Tobacco smoking using a waterpipe: a re-emerging strain in a global epidemic. Tobacco Control 2004; 13: 327-333.

[2] Maziak W, Ward K, Eissenberg T. Interventions for waterpipe smoking cessation. Cochrane Database Syst Rev. 2007 Oct 17;(4):CD005549.

[3] Chaouachi K. To whom does ‘public health’ belong when it comes to ‘Waterpipe’ Smoking ? Australian and New Zealand Journal of Public Health 2008; 32 (6): 583.

doi: 10.1111/j.1753-6405.2008.00319.x

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