Advertisement

Now is the Time for Effective Regulation Regarding Tobacco Smoking Using a Waterpipe (Hookah)

      See Related Article on p.800
      Rostron et al. [
      • Rostron B.L.
      • Wang B.
      • Liu S.T.
      Waterpipe or hookah-related poisoning events among U.S. adolescents and young adults.
      ] provide yet another analysis that highlights the immediate need for effective regulation of tobacco smoking using a waterpipe (hookah). This most recent report demonstrates, using data from the U.S. National Poison Database System, that smoking tobacco using a waterpipe can cause acute carbon monoxide (CO) poisoning that too often requires hospitalization. This systematic study corroborates numerous case reports from Australia [
      • Wang L.W.
      • He E.Y.
      • Ghosh D.
      • et al.
      Severe carbon monoxide poisoning from waterpipe smoking: A public health concern.
      ], England [
      • Clarke S.F.
      • Stephens C.
      • Farhan M.
      • et al.
      Multiple patients with carbon monoxide toxicity from water-pipe smoking.
      ], Italy [
      • La Fauci G.
      • Weiser G.
      • Steiner I.P.
      • Shavit I.
      Carbon monoxide poisoning in narghile (water pipe) tobacco smokers.
      ], Singapore [
      • Lim B.L.
      • Lim G.H.
      • Seow E.
      Case of carbon monoxide poisoning after smoking shisha.
      ], Turkey [
      • Cavus U.Y.
      • Rehber Z.H.
      • Ozeke O.
      • Ilkay E.
      Carbon monoxide poisoning associated with narghile use.
      ], and elsewhere [
      • de Suremain N.
      • Ngo J.
      • Loschi S.
      • et al.
      Carbon monoxide poisoning from waterpipe (narghile) smoking in a child.
      ,
      • von Rappard J.
      • Schönenberger M.
      • Bärlocher L.
      Carbon monoxide poisoning following use of a water pipe/hookah.
      ]. The data are clear: waterpipe tobacco smoking, which almost always involves inhalation of charcoal smoke in addition to tobacco smoke, is poisoning people worldwide.
      Acute CO poisoning is serious enough, but waterpipe smokers also inhale a host of other dangerous toxicants. Well-controlled studies demonstrate that smoking tobacco using a waterpipe exposes users to the dependence-producing, stimulant drug nicotine [
      • Blank M.D.
      • Cobb C.O.
      • Kilgalen B.
      • et al.
      Acute effects of waterpipe tobacco smoking: A double-blind, placebo-control study.
      ,
      • Jacob 3rd, P.
      • Abu Raddaha A.H.
      • Dempsey D.
      • et al.
      Nicotine, carbon monoxide, and carcinogen exposure after a single use of a water pipe.
      ], pulmonary disease-causing volatile aldehydes [
      • Al Rashidi M.
      • Shihadeh A.
      • Saliba N.A.
      Volatile aldehydes in the mainstream smoke of the narghile waterpipe.
      ,
      • Etemadi A.
      • Poustchi H.
      • Chang C.M.
      • et al.
      Urinary biomarkers of carcinogenic exposure among cigarette, waterpipe, and smokeless tobacco users and never users of tobacco in the Golestan Cohort Study.
      ,
      • Jawad M.
      • Eissenberg T.
      • Salman R.
      • et al.
      Toxicant inhalation among singleton waterpipe tobacco users in natural settings.
      ], cancer-causing polycyclic aromatic hydrocarbons [
      • Jacob 3rd, P.
      • Abu Raddaha A.H.
      • Dempsey D.
      • et al.
      Comparison of nicotine and carcinogen exposure with water pipe and cigarette smoking.
      ] and nitrosamines [
      • Kassem N.O.F.
      • Kassem N.O.
      • Liles S.
      • et al.
      Urinary NNAL in hookah smokers and non-smokers after attending a hookah social event in a hookah lounge or a private home.
      ], as well as a variety of toxic heavy metals such as cadmium and lead [
      • Khabour O.F.
      • Alzoubi K.H.
      • Al-Sheyab N.A.
      • et al.
      Plasma and saliva levels of three metals in waterpipe smokers: A case control study.
      ]. Given these toxicant exposures, there should be little surprise that waterpipe tobacco smoking has been associated with a variety of adverse health consequences including cancer, cardiovascular disease, chronic bronchitis, emphysema, and periodontal disease as well as obstetrical complications [
      • Bhatnagar A.
      • Maziak W.
      • Eissenberg T.
      • et al.
      Water pipe (hookah) smoking and cardiovascular disease risk: A scientific statement from the American Heart Association.
      ,
      • Waziry R.
      • Jawad M.
      • Ballout R.A.
      The effects of waterpipe tobacco smoking on health outcomes: An updated systematic review and meta-analysis.
      ,
      • El-Zaatari Z.M.
      • Chami H.A.
      • Zaatari G.S.
      Health effects associated with waterpipe smoking.
      ]. A growing body of high-quality research, much of it conducted in the last 15 years, provides ample evidence to support regulatory action to decrease waterpipe-caused morbidity and mortality.
      Yet, in most countries, very little effectively implemented regulation exists [
      World Health Organization
      An overview of global regulatory practices in controlling waterpipe tobacco use.
      ]. For example, in the U.S., waterpipe tobacco is sold with only one health warning label printed on the packaging in which the tobacco is contained (“WARNING: This product contains nicotine. Nicotine is an addictive chemical.”) [
      Food and Drug Administration
      Hookah tobacco (shisha or waterpipe tobacco).
      ] and regulation does not disallow misleading labeling such as “0.0% Tar” that perpetuates the myth that waterpipe smoke is not dangerous [
      • Vansickel A.R.
      • Shihadeh A.
      • Eissenberg T.
      Waterpipe tobacco products: Nicotine labelling versus nicotine delivery.
      ]. Although the U.S. Food and Drug Administration has the power to regulate the charcoal and the waterpipe apparatus [
      Food and Drug Administration
      Hookah tobacco (shisha or waterpipe tobacco).
      ], no labeling is required for these components. In addition, although clean indoor air laws exist in many U.S. states, venues that rent waterpipes and sell the tobacco for use on the premises (“hookah cafés”) too often are exempt. The air quality in these venues clearly is compromised [
      • Cobb C.O.
      • Vansickel A.R.
      • Blank M.D.
      • et al.
      Indoor air quality in Virginia waterpipe cafes.
      ,
      • Daher N.
      • Saleh R.
      • Jaroudi E.
      • et al.
      Comparison of carcinogen, carbon monoxide, and ultrafine particle emissions from narghile waterpipe and cigarette smoking: Sidestream smoke measurements and assessment of second-hand smoke emission factors.
      ,
      • Masjedi M.R.
      • Taghizadeh F.
      • Hamzehali S.
      • et al.
      Air pollutants associated with smoking in indoor/outdoor of waterpipe cafés in Tehran, Iran: Concentrations, affecting factors and health risk assessment.
      ] even when ventilation is mandated [
      • Seidenberg A.B.
      • Orlan E.N.
      • Travers M.J.
      • Sutfin E.L.
      Air quality and presence of air ventilation systems inside waterpipe cafés in North Carolina.
      ], but health warnings about the venues themselves are almost always absent. Given what is known about waterpipe toxicant emissions and health effects, these observations from the U.S., applicable globally [
      • Zaatari MD, G.S.
      • Bazzi A.
      Impact of the WHO FCTC on non-cigarette tobacco products.
      ], suggest a widespread regulatory failure at the national, state/provincial, and local level.
      Although Rostron et al. note that “…FDA is actively investigating scientific issues that can inform regulatory activities related to hookah tobacco” [
      • Rostron B.L.
      • Wang B.
      • Liu S.T.
      Waterpipe or hookah-related poisoning events among U.S. adolescents and young adults.
      ], the science exists to support effective national, state/provincial, and local regulation now. For example, the Rostron et al. report [
      • Rostron B.L.
      • Wang B.
      • Liu S.T.
      Waterpipe or hookah-related poisoning events among U.S. adolescents and young adults.
      ], in addition to many others, supports the notion that waterpipe venues (including their Web sites and other advertising) [
      • Asfar T.
      • Ben Taleb Z.
      • Osibogun O.
      • et al.
      How do waterpipe smoking establishments attract smokers? Implications for policy.
      ], waterpipe tobacco, waterpipe charcoal, and the waterpipe apparatus itself should be labeled to warn users and bystanders that, in addition to containing nicotine, waterpipe smoke contains CO that can cause poisoning that may require hospitalization. Also, the empirical work cited previously supports labeling on the venue and its advertising, waterpipe tobacco, charcoal, and apparatus that waterpipe smoke contains cancer-causing chemicals, waterpipe smoking causes cancer, emphysema, and may complicate pregnancy, and waterpipe smoking by pregnant women may result in fetal injury, premature birth, and low birth weight (the wording would be nearly identical to health warning labels on cigarette packaging in the U.S.) [
      Federal Trade Commission
      Cigarette labeling and advertising act.
      ]. Importantly, preliminary research suggests that people who have used waterpipe support the provision of this type of health-related information [
      • Darawad M.W.
      • Salloum R.
      • Alhussami M.
      • Maharmeh M.
      Evaluating health warning messages specific to waterpipe smoking among university students in Jordan.
      ]. Moreover, there is research underway to develop pictorial health warnings that may be particularly effective in reaching waterpipe tobacco smokers [
      • Asfar T.
      • Schmidt M.
      • Ebrahimi Kalan M.
      • et al.
      Delphi study among international expert panel to develop waterpipe-specific health warning labels.
      ,
      • Maziak W.
      • Ben Taleb Z.
      • Ebrahimi Kalan M.
      • et al.
      Pictorial health warning labels on the waterpipe device are effective in reducing smoking satisfaction, puffing behaviour and exposure to CO: First evidence from a crossover clinical laboratory study.
      ,
      • Mostafa A.
      • Mohammed H.T.
      • Hussein R.S.
      • et al.
      Do pictorial health warnings on waterpipe tobacco packs matter? Recall effectiveness among Egyptian waterpipe smokers & non-smokers.
      ].
      There are other regulatory actions that can be taken that can complement text and pictorial health warnings [
      World Health Organization
      ]. Addressing directly the issue highlighted by Rostron et al. [
      • Rostron B.L.
      • Wang B.
      • Liu S.T.
      Waterpipe or hookah-related poisoning events among U.S. adolescents and young adults.
      ], waterpipe venues should be subject to clean indoor air laws but, if for some reason they are not, these venues can be required to mount CO detectors that sound an alarm when ambient air CO concentrations rise beyond safe limits. At the population level, public awareness campaigns exist in many countries that address the adverse health consequences of cigarette smoking, and the science exists to inform similar campaigns addressing the adverse health consequences of waterpipe tobacco smoking. Some of these efforts are underway in specific locations [
      • Kearns R.
      • Gardner K.
      • Silveira M.
      • et al.
      Shaping interventions to address waterpipe smoking in Arabic-speaking communities in Sydney, Australia: A qualitative study.
      ,
      • Nakkash R.
      • Lotfi T.
      • Bteddini D.
      • et al.
      A randomized controlled trial of a theory-informed school-based intervention to prevent waterpipe tobacco smoking: Changes in knowledge, attitude, and behaviors in 6th and 7th graders in Lebanon.
      ,
      • Ramji R.
      • Nilsson M.
      • Arnetz B.
      • et al.
      Taking a stand: An untapped strategy to reduce waterpipe smoking in adolescents.
      ], but systematic, nationwide campaigns have been limited [
      • Tadena N.
      Truth campaign targets social smoking, hookahs as cigarette use declines.
      ]. Taxation, long understood to be an effective method of reducing cigarette smoking prevalence [
      ], can be applied to reduce waterpipe tobacco smoking. Existing data support these and numerous other effective regulatory strategies for reducing the morbidity and mortality of waterpipe tobacco smoking in the U.S. and across the globe (and there is a growing literature suggesting empirical support for the strict regulation of flavor additives in waterpipe tobacco) [
      • Leavens E.L.
      • Driskill L.M.
      • Molina N.
      • et al.
      Comparison of a preferred versus non-preferred waterpipe tobacco flavour: Subjective experience, smoking behaviour and toxicant exposure.
      ]. By highlighting waterpipe-induced CO poisoning, Rostron et al. [
      • Rostron B.L.
      • Wang B.
      • Liu S.T.
      Waterpipe or hookah-related poisoning events among U.S. adolescents and young adults.
      ] make clear that the time to implement effective regulation regarding tobacco smoking using a waterpipe is now.

      Funding Sources

      This work was supported by the National Institute on Drug Abuse of the National Institutes of Health under Award Number U54DA036105 and the Center for Tobacco Products of the U.S. Food and Drug Administration.

      References

        • Rostron B.L.
        • Wang B.
        • Liu S.T.
        Waterpipe or hookah-related poisoning events among U.S. adolescents and young adults.
        J Adolesc Health. 2019; 64: 804-806
        • Wang L.W.
        • He E.Y.
        • Ghosh D.
        • et al.
        Severe carbon monoxide poisoning from waterpipe smoking: A public health concern.
        Med J Aust. 2015; 202: 446-447
        • Clarke S.F.
        • Stephens C.
        • Farhan M.
        • et al.
        Multiple patients with carbon monoxide toxicity from water-pipe smoking.
        Prehosp Disaster Med. 2012; 27: 612-614
        • La Fauci G.
        • Weiser G.
        • Steiner I.P.
        • Shavit I.
        Carbon monoxide poisoning in narghile (water pipe) tobacco smokers.
        CJEM. 2012; 14: 57-59
        • Lim B.L.
        • Lim G.H.
        • Seow E.
        Case of carbon monoxide poisoning after smoking shisha.
        Int J Emerg Med. 2009; 2: 121-122
        • Cavus U.Y.
        • Rehber Z.H.
        • Ozeke O.
        • Ilkay E.
        Carbon monoxide poisoning associated with narghile use.
        Emerg Med J. 2010; 27: 406
        • de Suremain N.
        • Ngo J.
        • Loschi S.
        • et al.
        Carbon monoxide poisoning from waterpipe (narghile) smoking in a child.
        Arch Pediatr. 2019; 26: 44-47
        • von Rappard J.
        • Schönenberger M.
        • Bärlocher L.
        Carbon monoxide poisoning following use of a water pipe/hookah.
        Dtsch Arztebl Int. 2014; 111: 674-679
        • Blank M.D.
        • Cobb C.O.
        • Kilgalen B.
        • et al.
        Acute effects of waterpipe tobacco smoking: A double-blind, placebo-control study.
        Drug Alcohol Depend. 2011; 116: 102-109
        • Jacob 3rd, P.
        • Abu Raddaha A.H.
        • Dempsey D.
        • et al.
        Nicotine, carbon monoxide, and carcinogen exposure after a single use of a water pipe.
        Cancer Epidemiol Biomarkers Prev. 2011; 20: 2345-2353
        • Al Rashidi M.
        • Shihadeh A.
        • Saliba N.A.
        Volatile aldehydes in the mainstream smoke of the narghile waterpipe.
        Food Chem Toxicol. 2008; 46: 3546-3549
        • Etemadi A.
        • Poustchi H.
        • Chang C.M.
        • et al.
        Urinary biomarkers of carcinogenic exposure among cigarette, waterpipe, and smokeless tobacco users and never users of tobacco in the Golestan Cohort Study.
        Cancer Epidemiol Biomarkers Prev. 2019; 28: 337-347
        • Jawad M.
        • Eissenberg T.
        • Salman R.
        • et al.
        Toxicant inhalation among singleton waterpipe tobacco users in natural settings.
        Tob Control. 2019; 28: 181-188
        • Jacob 3rd, P.
        • Abu Raddaha A.H.
        • Dempsey D.
        • et al.
        Comparison of nicotine and carcinogen exposure with water pipe and cigarette smoking.
        Cancer Epidemiol Biomarkers Prev. 2013; 22: 765-772
        • Kassem N.O.F.
        • Kassem N.O.
        • Liles S.
        • et al.
        Urinary NNAL in hookah smokers and non-smokers after attending a hookah social event in a hookah lounge or a private home.
        Regul Toxicol Pharmacol. 2017; 89: 74-82
        • Khabour O.F.
        • Alzoubi K.H.
        • Al-Sheyab N.A.
        • et al.
        Plasma and saliva levels of three metals in waterpipe smokers: A case control study.
        Inhal Toxicol. 2018; : 1-5
        • Bhatnagar A.
        • Maziak W.
        • Eissenberg T.
        • et al.
        Water pipe (hookah) smoking and cardiovascular disease risk: A scientific statement from the American Heart Association.
        Circulation. 2019; ([Epub ahead of print])https://doi.org/10.1161/CIR.0000000000000671
        • Waziry R.
        • Jawad M.
        • Ballout R.A.
        The effects of waterpipe tobacco smoking on health outcomes: An updated systematic review and meta-analysis.
        Int J Epidemiol. 2017; 46: 32-43
        • El-Zaatari Z.M.
        • Chami H.A.
        • Zaatari G.S.
        Health effects associated with waterpipe smoking.
        Tob Control. 2015; 24: i31-i43
        • World Health Organization
        An overview of global regulatory practices in controlling waterpipe tobacco use.
        (Available at:)
        • Food and Drug Administration
        Hookah tobacco (shisha or waterpipe tobacco).
        (Available at:)
        • Vansickel A.R.
        • Shihadeh A.
        • Eissenberg T.
        Waterpipe tobacco products: Nicotine labelling versus nicotine delivery.
        Tob Control. 2012; 21: 377-379
        • Cobb C.O.
        • Vansickel A.R.
        • Blank M.D.
        • et al.
        Indoor air quality in Virginia waterpipe cafes.
        Tob Control. 2013; 22: 338-343
        • Daher N.
        • Saleh R.
        • Jaroudi E.
        • et al.
        Comparison of carcinogen, carbon monoxide, and ultrafine particle emissions from narghile waterpipe and cigarette smoking: Sidestream smoke measurements and assessment of second-hand smoke emission factors.
        Atmos Environ (1994). 2010; 44: 8-14
        • Masjedi M.R.
        • Taghizadeh F.
        • Hamzehali S.
        • et al.
        Air pollutants associated with smoking in indoor/outdoor of waterpipe cafés in Tehran, Iran: Concentrations, affecting factors and health risk assessment.
        Sci Rep. 2019; 9: 3110
        • Seidenberg A.B.
        • Orlan E.N.
        • Travers M.J.
        • Sutfin E.L.
        Air quality and presence of air ventilation systems inside waterpipe cafés in North Carolina.
        Tob Control. 2019; 28: 356-358
        • Zaatari MD, G.S.
        • Bazzi A.
        Impact of the WHO FCTC on non-cigarette tobacco products.
        Tob Control. 2018; ([Epub ahead of print])https://doi.org/10.1136/tobaccocontrol-2018-054346
        • Asfar T.
        • Ben Taleb Z.
        • Osibogun O.
        • et al.
        How do waterpipe smoking establishments attract smokers? Implications for policy.
        Subst Use Misuse. 2019; 54: 560-571
        • Federal Trade Commission
        Cigarette labeling and advertising act.
        (Available at:)
        • Darawad M.W.
        • Salloum R.
        • Alhussami M.
        • Maharmeh M.
        Evaluating health warning messages specific to waterpipe smoking among university students in Jordan.
        J Am Assoc Nurse Pract. 2019; 31: 133-138
        • Asfar T.
        • Schmidt M.
        • Ebrahimi Kalan M.
        • et al.
        Delphi study among international expert panel to develop waterpipe-specific health warning labels.
        Tob Control. 2019; ([Epub ahead of print])https://doi.org/10.1136/tobaccocontrol-2018-054718
        • Maziak W.
        • Ben Taleb Z.
        • Ebrahimi Kalan M.
        • et al.
        Pictorial health warning labels on the waterpipe device are effective in reducing smoking satisfaction, puffing behaviour and exposure to CO: First evidence from a crossover clinical laboratory study.
        Tob Control. 2019; ([Epub ahead of print])https://doi.org/10.1136/tobaccocontrol-2018-054682
        • Mostafa A.
        • Mohammed H.T.
        • Hussein R.S.
        • et al.
        Do pictorial health warnings on waterpipe tobacco packs matter? Recall effectiveness among Egyptian waterpipe smokers & non-smokers.
        PLoS One. 2018; 13: e0208590
        • World Health Organization
        (Available at:)
        • Kearns R.
        • Gardner K.
        • Silveira M.
        • et al.
        Shaping interventions to address waterpipe smoking in Arabic-speaking communities in Sydney, Australia: A qualitative study.
        BMC Public Health. 2018; 18: 1379
        • Nakkash R.
        • Lotfi T.
        • Bteddini D.
        • et al.
        A randomized controlled trial of a theory-informed school-based intervention to prevent waterpipe tobacco smoking: Changes in knowledge, attitude, and behaviors in 6th and 7th graders in Lebanon.
        Int J Environ Res Public Health. 2018; 15https://doi.org/10.3390/ijerph15091839
        • Ramji R.
        • Nilsson M.
        • Arnetz B.
        • et al.
        Taking a stand: An untapped strategy to reduce waterpipe smoking in adolescents.
        Subst Use Misuse. 2019; 54: 514-524
        • Tadena N.
        Truth campaign targets social smoking, hookahs as cigarette use declines.
        (Available at:)
      1. The economics of tobacco and tobacco control. National Cancer Institute, World Health Organization, Bethesda, MD/Geneva2016
        • Leavens E.L.
        • Driskill L.M.
        • Molina N.
        • et al.
        Comparison of a preferred versus non-preferred waterpipe tobacco flavour: Subjective experience, smoking behaviour and toxicant exposure.
        Tob Control. 2018; 27: 319-324

      Linked Article