Waterpipe Tobacco Smoking: an Emerging Health Crisis in the United States

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Waterpipe Tobacco Smoking: An Emerging Health Crisis in the United States

Caroline Cobb, MS; Kenneth D. Ward, PhD; Wasim Maziak, MD, PhD; Alan L. Shihadeh, ScD; Thomas Eissenberg, PhD

Objective: To examine the preva- waterpipe session produces the lence and potential health risks equivalent of at least 1 and as of waterpipe tobacco smoking. many as 50 cigarettes. Miscon- Methods: A literature review was ceptions about waterpipe smoke performed to compile information content may lead users to under- relating to waterpipe tobacco estimate health risks. Conclusion: smoking. Results: Waterpipe to- Inclusion of waterpipe tobacco bacco smoking is increasing in smoking in tobacco control ac- prevalence worldwide; in the tivities may help reduce its spread. United States, 10-20% of some Key words: waterpipe tobacco young adult populations are cur- smoking, prevention, adolescent rent waterpipe users. Depending behavior on the toxicant measured, a single Am J Health Behav. 2010;34(3):275-285

obacco use causes many of the ing the tobacco epidemic over the past 20 world’s leading lethal ailments, in- years.2 This success is threatened by cluding cardiovascular disease, alternative methods of tobacco use, in- T 3,4 chronic obstructive pulmonary disease, cluding waterpipe tobacco smoking. and lung cancer.1 In the United States, Waterpipe tobacco smoking is a centu- tobacco smoking remains the leading pre- ries-old tobacco use method with an am- ventable cause of death, even as consid- biguous origin5 and links to the countries erable success has been achieved in curb- of southwest Asia and north Africa. Al- though known by many different names (eg, hookah, narghile, shisha), the term waterpipe has been used for the last 2 Caroline Cobb, Graduate Student, Department decades in the English language scien- of Psychology, Virginia Commonwealth University, tific literature6-10 to refer to any of a vari- Richmond, VA. Kenneth D. Ward and Wasim Maziak, Associate Professors, Department of Health ety of instruments that involve passing and Sport Sciences and Center for Community tobacco smoke through water before in- Health The University of Memphis, Syrian Center halation. Contrary to popular belief that for Tobacco Studies, Aleppo, Syria, Memphis, TN. waterpipe tobacco smoking is less lethal Alan L. Shihadeh, Associate Professor, Department than cigarette smoking,9,11 emerging re- of Mechanical Engineering, American University of search indicates that both involve com- Beirut, Lebanon. Thomas Eissenberg, Professor, parable health risks3,4,12 including nico- Department of Psychology and Institute for Drug tine/tobacco dependence.13,14 In addition, and Alcohol Studies, Virginia Commonwealth Uni- waterpipe tobacco smoking may be, for versity, Syrian Center for Tobacco Studies, Aleppo, some individuals, a precursor to cigarette Syria, Richmond, VA. 15-17 Address correspondence to Dr Eissenberg, De- smoking. All of these issues are rel- partment of Psychology and Institute for Drug evant to the United States, where and Alcohol Studies, Virginia Commonwealth waterpipe tobacco smoking appears to be University, Box 980205, Richmond, VA 23298. increasing in popularity. Thus, this re- E-mail: [email protected] view addresses this emerging tobacco

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Figure 1 A Waterpipe Prepared for Tobacco Smoking, Including Perforated Foil Separating the Charcoal from the Tobacco That Has Been Placed in the Head

use method in the United States by high- What Are Waterpipes and How Are lighting current data regarding its preva- They Used to Smoke Tobacco? lence and potential health effects, as well Although composition details may dif- as the knowledge, beliefs, and attitudes fer by culture, tobacco waterpipes most associated with, and potentially fueling, often seen in the United States have a the spread of this tobacco use method. fired-clay head, metal body, glass or acrylic Our goals include increasing awareness, water bowl, and leather or plastic hose stimulating research, influencing policy, (Figure 1). The bowl is partially filled with and developing effective prevention and water and the head is filled with moist- treatment interventions. ened tobacco upon which a lit piece of

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Table 1 Mean Puff Topography for Waterpipe Users and Cigarette Smokers

Waterpipe Cigarette Topography variable N = 2024 N =5222 N = 3025 N = 5626

Puff number 178 171 10.0 12.7 Puff volume (ml) 590 530 51.0 48.6 Puff duration (s) 2.8 2.6 1.4 1.5 Interpuff interval (s) 15.2 15.5 30.7 21.3

charcoal is placed (tobacco and charcoal Waterpipe Tobacco Smoking in the are often separated by perforated alumi- United States num foil). The smoker inhales through Waterpipe tobacco smoking is often as- the hose, thus drawing air over the burn- sociated with southwest Asia and north ing charcoal, heating the tobacco, and Africa but, in recent years, has spread producing smoke that travels through the across the globe and to the United States. body of the waterpipe, the water, and the In this country, several lines of evidence hose to the user.18 The most popular type suggest that waterpipe tobacco smoking is of waterpipe tobacco is called maassel becoming more common, especially on (also known as shisha tobacco), a wet college campuses. First, in April 2004, mixture of tobacco, sweetener, and flavor- Smokeshop magazine (a 30- year-old trade ings. Maassel comes in many flavors, journal serving the tobacco industry) re- including fruit and candy, and it produces ported that 200-300 new waterpipe cafés an aromatic smoke that may be particu- had opened in the United States since larly appealing to youth.19 Waterpipe char- 1999 and that these cafés were “often near coal products range from traditional college campuses.”27 Second, recent press earthen kiln charcoal to quick-lighting reports support the idea that the United products that are particularly common in States is in the early stages of a waterpipe the United States.20 epidemic among its college-age popula- Relative to a single cigarette, com- tion: waterpipe use has been reported in at pleted in about 5 minutes,21 a single least 33 states, with most reports coming waterpipe use episode typically lasts for from cities with a large university.28-35 As about 1 hour.18 Recent technical innova- one recent letter in the American Journal of tions22-24 confirm this duration and also Public Health noted: “In Pittsburgh, 4 hoo- provide a more detailed analysis of kah bars have opened since 2003, each no waterpipe tobacco smoking episodes. As more than 5 miles from the campuses of seen in Table 1, data collected from actual Carnegie Mellon University and the Uni- waterpipe tobacco smokers in natural versity of Pittsburgh. Hookahs have be- settings show that a waterpipe use epi- come commonplace at fraternity parties at sode typically involves almost 200 puffs, these universities. . .”36 with an average puff volume exceeding These anecdotal reports are beginning 500 ml.22,24 Thus, compared to a cigarette, to be corroborated by survey data from which involves inhalation of approximately individual universities across the coun- 500-600 ml of smoke (ie, 10-13 puffs of try (Figure 2, Panel B). For example, in a about 50 ml, on average25,26), a single convenience sample survey of 411 Johns waterpipe use episode involves inhala- Hopkins University freshmen (100%

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Figure 2 Percent of Respondents from Locations in Southwest Asia19,37 and North America11,38,39 Reporting Lifetime and Past 30-day Waterpipe (WP) Tobacco Smoking

100 AB100 Southwest Asia North America 80 80 Lifetime WP use 60 Past 30-day WP use 60 40 40 Percent (%) Percent (%) 20 20

0 0 Aleppo, Syria Beirut, Lebanon Baltimore, MD Richmond, VA Pittsburgh, PA N = 58719 N = 41637 N = 41111 N = 74438 N = 64739

pling procedures, 40.5% of 647 students rettes (23% vs 15%, respectively).43 Many who responded to an e-mail survey re- waterpipe users in this survey reported ported ever using a waterpipe to smoke that they first used the waterpipe before tobacco, with 9.5% reporting waterpipe the age of 10.43 In a study of a convenience tobacco smoking in the past 30 days.39,40 sample of 1872 14- to 18-year-olds in the Thus, especially among university stu- US Midwest, 16.7% Arab American youth, dents, waterpipe tobacco smoking has and 11.3% non-Arab youth reported past- become remarkably common in the month waterpipe use.44 Clearly, cultural United States. The spread of waterpipe factors may be important in understand- tobacco smoking may be attributable, at ing waterpipe use among these Arab least in part, to the ready commercial American populations, and more work availability of flavored tobacco and quick- addressing this issue is necessary. lighting charcoal.9 In the United States, Waterpipe tobacco smoking is also sur- these and other waterpipe-related prod- prisingly common in more diverse popu- ucts commonly are purchased via the lations:, among 6594 Arizona students Internet.20 (grades 6 thru 12) who responded to the Recent work in Southwest Asia and the Youth Tobacco Survey, 7.3% of 12th grad- United States suggests that some indi- ers and 3.5% of all students reported past viduals begin smoking tobacco using a 30-day waterpipe use.45 All of these data waterpipe at a young age. For example, in addressing youth are important because, a survey of 2443 Lebanese students (11 to at least for cigarette smoking, earlier 17+ years old; M=15) from public and pri- initiation is associated with longer dura- vate secondary schools in greater Beirut, tion of smoking and increased risk of 64.9% reported that they had tried nicotine dependence and deleterious waterpipe at some point in their life, and health effects.46 Moreover, waterpipe to- 25.6% reported past 30-day use.41 Also, bacco smoking in the United States may among 388 Israeli schoolchildren aged be introducing tobacco to an otherwise 12-18, 41% reported current waterpipe tobacco-naïve group of adolescents and tobacco smoking, and 22% reported that young adults. In Pittsburgh, 35.4% of uni- they used a waterpipe to smoke tobacco versity students who use a waterpipe had every weekend.42 In the United States, a never smoked a cigarette.39 survey of 1671 Arab American adoles- The fact that many waterpipe tobacco cents found that 26.6% reported ever use smokers are otherwise tobacco naïve is of a waterpipe, and by the age of 14, more worrisome, in part because waterpipe to- adolescents had tried waterpipe than ciga- bacco smoking may become a gateway to

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initiation of cigarette smoking.15 Such a prospect is plausible given that waterpipe Table 2 tobacco smoking is time-consuming and Machine-generated Smoke largely sedentary: active individuals who enjoy the effects of smoking tobacco with Content Using Realistic Puff a waterpipe may turn to cigarettes for a Parameters for a Single more convenient and mobile smoking Waterpipe Episode and a method. Evidence from cross-sectional Single Cigarette study of Arab American adolescents shows that the odds of experimenting with ciga- Toxicant rettes were 8 times greater for those who (mg) Waterpipe23 Cigarette26 Ratio have ever smoked tobacco using a waterpipe.43 In a population-based study of Nicotine 2.94 1.74 1.7 young adult US military recruits, waterpipe CO 145 22.3 6.5 users were more likely than nonusers to Tar 802 17.3 46.36 plan to initiate cigarette smoking in the next year.16 Thus, preliminary data suggest that the waterpipe can become a waterpipe tobacco smoking is likely asso- vector to highly lethal and addictive ciga- ciated with substantial toxicant exposure. rette smoking. There is less evidence Although more research is needed, pre- that waterpipe tobacco smoking is associ- liminary evidence supports the notion ated with marijuana use: in a survey of that waterpipe tobacco smokers are ex- 201 US waterpipe tobacco smokers, 64.2% posed to a variety of smoke toxicants. For reported not having used marijuana in example, a meta-analysis of studies look- the past 30 days, and only 10.4% reported ing at waterpipe users’ exposure to the that they smoked marijuana and tobacco psychoactive and dependence-producing in the same waterpipe.20 drug nicotine shows that daily waterpipe use produces a urinary cotinine level To What Toxicants Are Waterpipe that corresponds to a nicotine absorption Users Exposed? rate equal to smoking 10 cigarettes per For some tobacco smoke toxicants (eg, day.48 CO, a smoke toxicant that reduces nicotine, carbon monoxide, or CO), the the blood’s ability to carry oxygen, can also smoke content and user toxicant expo- be found in waterpipe users,50 and sure associated with waterpipes is at waterpipe-induced increases in expired least comparable to that of cigarettes.10,47,48 air CO may far exceed those produced by In terms of smoke toxicant content, when a cigarette.51,52 Indeed, in a recently pub- waterpipe tobacco smoke is generated by lished study of waterpipe users in Califor- a machine that is programmed to imitate nia, waterpipe tobacco smoking led to a the puff parameters of actual waterpipe mean increase in expired air CO of over users, substantial amounts of nicotine, 30 ppm,10 about 5 times that which would CO, and tar (nicotine-free dry particulate be expected from a single cigarette.eg,25 matter) can be measured in the smoke.18,23 Thus far, there has been little empirical As Table 2 shows, the levels of CO and tar attention paid to users’ exposure to other produced by a single waterpipe use epi- toxicants in waterpipe smoke, including sode are substantially greater than those lung carcinogens23,53 and heavy metals.18,54 found in the smoke generated by a ma- Recent research has shown that chine programmed to smoke a single waterpipe smoke may contain a variety of cigarette using puffing parameters ob- specific toxicants found in cigarettes. For served in cigarette smokers. In fact, these example, machine-generated waterpipe data suggest that, relative to a single smoke contains alarming levels of vola- cigarette (about 500 ml of smoke, see tile aldehydes such as formaldehyde, ac- Table 1), a single waterpipe use episode etaldehyde, and acrolein, all compounds (about 90,000 ml of smoke, see Table 1) is present in cigarette smoke.55 Another associated with 1.7 times the nicotine, toxicant of interest is the isotope 210Po, 6.5 times the CO, and 46.4 times the tar. which is a member of the uranium decay Although extrapolating this type of smoke series and present in tobacco and tobacco content analysis to actual cigarette or smoke.56 Entering smokers’ bodies via waterpipe smokers has important limita- inhaled smoke 210Po is capable of deliver- tions (see 23,49), these data suggest that ing powerful radiation doses and thus

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radiotoxic effects to humans.56,57 Although waterpipe, the health effects of this the activity concentrations of 210Po in 2 method of tobacco smoking have not been forms of waterpipe tobacco may be lower as clearly documented as for cigarettes, than those in cigarette tobacco, the per- perhaps due to a lack of adequate re- centage of 210Po released in the smoke sources in the world regions where stream is still high (>39%, see 58,59). Taken waterpipe tobacco smoking traditionally together, all of the data concerning has occurred. The available evidence, waterpipe tobacco toxicant content raise although scant, suggests that waterpipe important concerns, as decades of re- tobacco smokers, like cigarette smokers, search on cigarette smokers demonstrate are at risk for nicotine/tobacco depen- that prolonged exposure to these toxi- dence, cardiovascular disease, and can- cants leads to significant adverse health cer. effects.60 Dependence is thought to represent However, based on existing data, there cellular adaptation to chronic drug is little evidence to support the percep- exposure.eg,67,68 The potential for waterpipe tion that passing the smoke through wa- use to support dependence is based on the ter reduces toxicant exposure.18 There fact that waterpipe smoke delivers the may be more reason to believe that the dependence-producing drug nicotine.48 lower temperatures attained by waterpipe Because cellular adaptations are difficult tobacco (approximately 450oC for to observe in humans, drug dependence waterpipe vs 900oC degrees for cigarette18) is characterized behaviorally by repeated reduce mutagenicity of the smoke com- drug self-administration despite known ponents originating in the tobacco61 health risks, financial costs, and quit though the same is not true for the com- attempts.69 Abstinence effects that are ponents originating in the charcoal. In suppressed by drug administration are any case, discussions of whether the water also dependence indicators.70 Although or the tobacco temperature reduces more systematic study is required, at smoke toxicant content from some maxi- least some users perceive waterpipe to- mal level may be made moot by the fact bacco smoking to be detrimental to their that, in a single use episode with water in health and may not be able to quit easily: the waterpipe and a relatively low tobacco in one study, 28.4% of waterpipe users temperature, a waterpipe produces an indicated an interest in quitting, with average of 90,000 ml of smoke that, rela- over half of these reporting a past-year tive to a single cigarette, contains about unsuccessful quit attempt.71 Also, in a 6 times the CO (Table 2), 46 times the tar recent survey of US waterpipe users, (see Table 2), and more than 50 times the 12.9% (24/186) said that they were quantity of some carcinogenic polycyclic “hooked on a waterpipe.”20 Still, emerging aromatic hydrocarbons,53 as well as heavy evidence suggests higher quit rates metals such as lead and arsenic.18 among waterpipe users compared to ciga- Exposure to waterpipe-associated toxi- rette smokers.16,72 cants is not restricted to users; nearby One way to assess drug dependence is nonsmokers may also be exposed. Recent to terminate drug administration: depen- studies show that mainstream smoke from dence is revealed by abstinence-induced a waterpipe contains high levels of fine effects that are suppressed by subsequent particulate matter,62,63 which can be an drug administration.73-75 Importantly, ab- important cardio-respiratory hazard.64,65 A stinent daily waterpipe users report with- considerable proportion of these particles drawal symptoms that are suppressed by 17 (eg, PM2.5) are emitted by waterpipe tobacco waterpipe use. Thus, although more smokers to the surrounding air, reaching study is clearly needed, available evi- levels compared to those associated with dence from surveys and clinical labora- cigarette smoking.66 These data justify tory studies support the idea that tobacco inclusion of waterpipe cafés and lounges in smoking using a waterpipe supports to- current clean indoor air policies aimed at bacco/nicotine dependence. protecting customers and workers of these Waterpipe-induced tobacco/nicotine establishments. dependence is likely to share features with cigarette smoking (ie, those medi- What Are the Health Effects of ated by nicotine), but may also have dis- Waterpipe Tobacco Smoking? tinct features attributable to waterpipe- Despite the long history of the specific characteristics such as setting

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and time of use, accessibility, taste and lethal due to the presumed but unsub- smell of flavored waterpipe smoke.13 To stantiated “filtering” effects of the water.9 the extent that empirical study reveals Indeed, several recent US college-based these distinct features of waterpipe-in- studies show that the majority of duced dependence, they will need to be waterpipe tobacco smokers perceive this accounted for as smoking cessation in- tobacco use method as being less harmful terventions for waterpipe users are de- and addictive than cigarettes.17,20 veloped.9 Another component of the “reduced” More research is also needed to clarify harm/addictiveness perception among waterpipe-induced risk of other tobacco- waterpipe users may be related to the caused diseases, such as cardiovascular predominantly intermittent use pattern disease and cancer. The existing litera- of this tobacco use method.13 However, ture has been reviewed elsewhere3,4 and intermittent waterpipe tobacco smoking demonstrates that waterpipe use may be does not preclude dependence develop- associated with coronary heart disease,76 ment – in cigarette smokers, symptoms a variety of negative pulmonary out- of nicotine dependence and withdrawal comes,77,78 and bronchogenic carci- can appear with intermittent smoking.90,91 noma.79,80 A recent study demonstrated Also, the fact that a single episode of that, relative to nonsmokers, both daily waterpipe smoking can involve volumes waterpipe tobacco smokers and daily ciga- of tobacco smoke that are orders of mag- rette smokers had higher levels of nitude greater than a single cigarette carcinoembryonic antigen (CEA), a pro- suggests that intermittent waterpipe to- tein associated with tumor formation.81 bacco smoking may involve substantial In addition, an epidemiological study sug- levels of smoke toxicant exposure. gests that heavy waterpipe users have Aside from perceptions regarding significantly higher levels of CEA in com- health risks and addiction, many young parison to nonsmoking healthy controls.82 waterpipe users are attracted to the aro- Waterpipe tobacco smoking also increases matic smell of waterpipe smoke and the micronucleus (MN) frequency, a marker opportunity it provides for social interac- for early identification of carcinogen- tion.3,9,92 In particular, the social dimen- esis.12,83 Waterpipe smoking is also a risk sion has emerged in several studies from to dental84,85 and fetal health.86-88 Finally, countries in southwest Asia (reviewed in because waterpipe tobacco smoking is reference 3). In qualitative studies among often a social behavior that involves shar- Arab American adolescents, waterpipe ing the same waterpipe, it may increase use has been viewed as being “cool” and a the risk of infectious disease transmis- way to socialize with friends.92 Socializing sion.89 Disposable mouthpieces are avail- is a common theme in the few studies able to address this concern, though their conducted in the United States: in one, acceptability, actual use, and ultimate 79% of 201 waterpipe tobacco smokers effectiveness are unknown. Importantly, surveyed reported that they smoked to- causal links between waterpipe tobacco bacco in a waterpipe at least in part be- smoking and these various health risks cause it is a good way to socialize with are uncertain, due to small sample sizes friends.20 Indeed, a series of recent stud- used in the few existing studies, concur- ies among US college students suggests rent or prior cigarette use among the that the majority of waterpipe users view studied individuals, and other potentially the practice as socially acceptable.20,38,39 confounding factors.3,4 As waterpipe to- Perhaps more than with cigarette smok- bacco smoking spreads across the globe, ing, effective waterpipe prevention inter- rigorous study and clear communication ventions will need to deal with the mis- regarding its potential effects on health conceptions related to health risks asso- will be required. ciated with waterpipe use and address some specific features of this tobacco use What Do People Believe About method, including its value and stimulus Waterpipes? for social behavior. One of the defining features of the global resurgence in waterpipe use is the CONCLUSIONS AND IMPLICATIONS widespread perception that, relative to Waterpipe tobacco smoking is a grow- tobacco cigarette smoking, tobacco smoking health concern globally and especially ing using a waterpipe is likely to be less among young adults in the United States.

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Many waterpipe tobacco smokers perceive paigns – we may be able to halt and this behavior to be less lethal and addict- eventually reverse its spread among ing than cigarettes.20 Converging lines of American youth. evidence, including waterpipe smoke analysis, user toxicant exposure, and Acknowledgments health effects research contradict this Sources of support include National perception, though more study is re- Institute on Drug Abuse grant quired.83 As more detailed study contin- R01DA024876, National Cancer Institute ues, physicians, policy makers, and to- grants R01CA103827 and R01CA120142, bacco control advocates can play an im- and Fogarty International Center grant portant role in addressing perceptions R01TW05962. and minimizing the spread of waterpipe tobacco smoking. REFERENCES One important step that can be taken 1.World Health Organization. Factsheet No. 310: immediately is that health care providers The top 10 causes of death. 2007. Available at can include waterpipe tobacco smoking http://www.who.int/mediacentre/ factsheets/fs310/en/print.html. Accessed when evaluating patients, especially ado- August, 1, 2007. lescents and young adults. This inclusion 2.Centers for Disease Control and Prevention. could come in the form of explicit mention Cigarette smoking among adults — United of waterpipe when implementing stan- States, 2006. MMWR Morb Mortal Wkly Rep. dardized assessments93 and clear state- 2007;56(44):1157-1161. ments that waterpipe tobacco smoke con- 3.Maziak W, Ward KD, Soweid RA, Eissenberg tains many of the same toxicants as ciga- T. Tobacco smoking using a waterpipe: a re- rette smoke. On an individual level, the emerging strain in a global epidemic. Tob addition of waterpipe in assessments of Control. 2004;13:327-333. 4.Knishknowy B, Amitai Y. Water-pipe (Narghile) tobacco use may help counteract the per- smoking: an emerging health risk behavior. ception that this form of tobacco use is Pediatrics. 2005;116(1):e113-e119. benign. 5.Chattopadhyay A. Emperor Akbar as a healer To date, waterpipe tobacco smoking and his eminent physicians. Bull Indian Inst has received little attention in system- Hist Med Hyderabad. 2000;30:151-157. atic surveillance, large-scale social 6.Lubin JH, Li JY, Xuan XZ, et al. Risk of lung marketing campaigns, prevention inter- cancer among cigarette and pipe smokers in ventions, and other tobacco control ac- southern China. Int J Cancer. 1992;51(3):390- tivities. For example, most national sur- 395. veys of tobacco use do not explicitly assess 7.Inhorn MC, Buss KA. Ethnography, epidemiology and infertility in Egypt. Soc Sci Med. waterpipe tobacco smoking, making 1994;39(5):671-686. prevalence estimates difficult. Similarly, 8.Bedwani R, el-Khwsky F, Renganathan E, et clean indoor air legislation in many states al. Epidemiology of bladder cancer in Alexan- has been unclear concerning whether dria, Egypt: tobacco smoking. Int J Cancer. waterpipe smoking establishments (eg, 1997;73(1):64-7. “hookah cafés”) fall under criteria that 9.Maziak W, Ward KD, Eissenberg T. Interven- prohibit or limit their operation.94 Also, tions for waterpipe smoking cessation. more must be done to limit minors’ ac- Cochrane Database Syst Rev. cess to waterpipe products, enforce clear 2007;(4):CD005549. 10.El-Nachef WN, Hammond SK. Exhaled car- warning labels on waterpipe tobacco, and bon monoxide with waterpipe use in US ensure that common but misleading de- students. JAMA. 2008;299(1):36-38. scriptors such as “0% tar” are removed 11.Smith SY, Curbow B, Stillman FA. Harm from packaging. Until waterpipe tobacco perception of nicotine products in college smoking is included in these and other freshmen. Nicotine Tob Res. 2007;9(9):977- interventions, many young adults are 982. likely to maintain their belief that it is 12.El-Setouhy M, Loffredo CA, Rawan G, et al. less lethal than cigarette smoking. In- Genotoxic effects of waterpipe smoking on the deed, some may already interpret the buccal mucosa cells. Mutation Res. 2008;655:36-40. absence of waterpipe tobacco smoking 13.Maziak W, Eissenberg T, Ward KD. Patterns from these activities as implied endorse- of waterpipe use and dependence: implica- ment of this perception. By including tions for intervention development. Pharmacol waterpipe tobacco smoking in all levels of Biochem Behav. 2005;80:173-179. tobacco control – from individual provid- 14.Al Mutairi SS, Shihab-Eldeen AA, Mojiminiyi ers to large-scale public information cam- OA, Anwar AA. Comparative analysis of the

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