The Waterpipe: a New Global Threat to CV Health?

gOPINIONEDITORIAL VIEWPOINT The Waterpipe: A New Global Threat to CV Health?

Wasim Maziak Miami, FL, USA

Tobacco smoking continues to be the number able evidence however, suggests that waterpipe one preventable cause of morbidity and mortality, smoking is addictive and is associated with smok- contributing to millions of deaths every year and ing-related diseases such as lung cancer, respiratory wreaking havoc on the welfare of families and com- disease, and low birth weight [10]. Despite these munities worldwide. Most of the brunt of the to- worrisome trends, tested policies and interventions bacco epidemic is borne by developing countries, a to combat waterpipe smoking are still nascent. trend that is likely to accelerate [1]. Several evi- The triad of increasing popularity, harmful and dence-based interventions and policies have been addictive properties, and lack of effective policies advanced in the past decades to limit smoking ini- represent the main pillars of the waterpipe epidemic tiation and help dependent smokers quit. Although that will be discussed later in this paper. these have been successful in general, they have pri- marily focused on cigarette smoking. Yet, for many youths worldwide, tobacco use and addiction is THEGLOBALEPIDEMICOFWATERPIPE maintained by means other than the cigarette. In SMOKING particular, over the past decade, waterpipe smoking has dramatically become the most widespread to- Epidemiological trends of waterpipe smoking are bacco use method among youth in the Eastern very alarming, and what started in the 1990s as a Mediterranean Region (EMR) and is rapidly ‘‘social’’ phenomenon among youths in the EMR spreading globally [2]. soon became a global trend [2]. In the EMR, prev- The waterpipe, known in many cultures under alence estimates of waterpipe smoking among different shapes and names (e.g., hookah, shisha, youth, have already surpassed those of cigarette narghile), is a centuries-old tobacco-use method smoking, and the rest of the world is catching up. that has traditionally been associated with Middle Studies show that about one-quarter of youths in Eastern societies. The emergence of waterpipe societies of the EMR are current (past month) smoking as a global threat to public health is evi- waterpipe smokers [5]. Recent evidence from dis- denced by the sharp increase in the past decade of perse populations and societies worldwide print a studies, news, and professional reports devoted to worrisome picture of a global spread (e.g., United the waterpipe [3–8]. In the waterpipe, charcoal- States, Canada, United Kingdom, Estonia, Ger- heated air passes through a perforated aluminum many, Denmark, Pakistan, Iran, South Africa, foil separating the charcoal from the ﬂavored tobac- France, Australia) [11]. For example, waterpipe co (a.k.a. Maassel) to become smoke that cools as it smoking is steadily becoming the second most pop- bubbles through the water on its way to the smoker. ular form of tobacco use among college students in The passage of smoke through water underlies the United States, as seen from a large survey much of the widespread misperception about water- (n = 3,770) of students from 8 universities in North pipe’s ‘‘reduced’’ harm and addictiveness [9]. Avail- Carolina. According to this survey, ever waterpipe

This work is supported by the National Institute on Drug Abuse (NIDA) Grant R01 DA024876. From the Department of Epidemiology, Robert Stempel College of Public Health and Social Work, Florida International University, Miami, FL, USA. Correspondence: W. Maziak (wmaziak@ﬁu.edu). 180 Maziak GLOBAL HEART, VOL. 7, NO. 2, 2012 July 2012: 179–181 The Waterpipe: A New Global Threat to CV Health?

smoking was reported by 40% of students, whereas nicotine that produces dependence, CO that causes current waterpipe smoking was reported by 17%, cardiovascular disease, and polycyclic aromatic which is second only to cigarettes [12]. The global hydrocarbons that cause cancer [2]. In fact, due spread of waterpipe smoking among youths is best to the involvement of charcoal, some of the impor- revealed by the Global Youth Tobacco Survey; the tant smoke toxicants (e.g., polycyclic aromatic largest surveillance to date of tobacco use among hydrocarbons, CO) are produced at much greater youths with 209 surveys conducted in 95 countries. levels in waterpipes compared with cigarettes Time trends from the Global Youth Tobacco Sur- [18,19]. Furthermore, even though intermittent vey (1999 to 2008) involving more than half a mil- use of a waterpipe can imply reduced exposure, it lion 13- to 15-year-olds worldwide show that while is important to note that the amount of smoke in- cigarette smoking is either stable or declining haled in a single waterpipe session averages about worldwide, other forms of tobacco are showing a 150 times that of a single cigarette [19]. rising trend, most notably waterpipe smoking Studies of the acute effects of waterpipe smok- [13]. In epidemiological terms, such trends cover- ing on the cardiovascular system have reported a ing vast geographical territories and diverse socie- similar picture to the one seen with cigarette smok- ties and encompassing several age groups can very ing. For example, waterpipe smoking is associated unlikely mean a passing fad, but signify an epi- with an increase in heart rate, systolic and diastolic demic that has taken hold among youths, and with blood pressure, and markedly impaired baroreflex the potential only to exacerbate unless we do some- sensitivity [5,20]. However, the long-term effects thing about it. of waterpipe smoking on the cardiovascular system have not yet been studied. This is perhaps due in part to the relative novelty of the current waterpipe WATERPIPE ADDICTIVE AND HARMFUL epidemic compared with the known latency be- PROPERTIES WITH EMPHASIS ON tween smoking initiation and the development of CARDIOVASCULAR HEALTH serious smoking-related cardiovascular outcomes such as coronary ischemia and myocardial infarc- In 1997, Macaron et al. [14] first showed nicotine tion. Available evidence, however, suggests that exposure in waterpipe smokers by measuring coti- the cardiovascular system can be at particular risk nine in their urine, a finding that has been repli- from waterpipe smoking. Given that CO is among cated since. Our own work in waterpipe smokers the most important cardiovascular toxicants, the demonstrated dependence features of failed quit at- fact that waterpipe smokers are exposed to high tempts, self-perception of being ‘‘hooked’’ on the CO levels and for extended periods can be particu- waterpipe, use escalation over time, behavioral larly alarming. This is supported by emerging re- adaptations to ensure access, and abstinence-in- ports of waterpipe-related emergency room duced withdrawal that is suppressed by subsequent admissions due to acute CO intoxication, an ad- waterpipe use [2]. For example, in a random sample verse event that has not been reported with ciga- of 268 waterpipe users in Aleppo, 28% wanted to rette smoking [2]. Particulate matter, another quit and 59% had made an unsuccessful quit at- important toxicant for the cardiovascular system is tempt in the past year. Belief in one’s ability to quit also produced at higher levels during waterpipe was inversely related to perceived dependence [13]. smoking compared with cigarettes [21–23]. Case histories from waterpipe users provide another line of evidence of its addictiveness: ‘‘I like to dominate everything, but the narghile has com- THE FAILURE OF TOBACCO CONTROL pletely dominated me’’ [15]. As important, per- POLICY TO ADDRESS WATERPIPE haps, is our finding that the waterpipe may SMOKING mediate failed quit attempts in cigarette smokers, which can seriously undermine tobacco-control ef- Despite alarming trends of waterpipe use, there is a forts [16,17]. failure of policies and regulations to address water- While high-quality studies of the long-term pipe smoking. For example, there is a perception health effects of waterpipe smoking are still lack- that a safer product can be reinforced by wide- ing, available evidence implicates the waterpipe in spread deceptive and promotional descriptors on cancer, respiratory disease, and low birth weight waterpipe products (e.g., contains 0% tar and [8]. Smoke from a waterpipe contains many of 0.05% nicotine, diet, herbal, tobacco free, healthy), the toxicants found in cigarette smoke, including as well as the exemption of waterpipe venues from GLOBAL HEART, VOL. 7, NO. 2, 2012 Maziak 181 July 2012: 179–181 The Waterpipe: A New Global Threat to CV Health?

most indoor air and minors’ access laws [2,24–26]. the United States prohibits the sale of flavored Moreover, the Framework Convention on Tobacco cigarettes, but flavored waterpipe tobacco is not Control (FCTC), the first global treaty intended to prohibited. reduce tobacco use, is formulated with the cigarette and the tobacco industry in mind [2,24]. In fact, even in places where FCTC policies are enforced, RECOMMENDATIONS waterpipe products do not usually comply with FCTC restrictions. For example, recent studies Waterpipe smoking bears all the signs of a burgeon- show that most waterpipe products do not comply ing global epidemic with grave potential on future with FCTC’s size provisions for health warnings, tobacco-related morbidity and mortality. Given and display false and deceptive descriptors about waterpipe use’s global reach and its serious public their content of harmful substances such as nico- health implications, we need to act quickly with a tine and tar [24,27]. The same situation is also comprehensive response of evidence-based inter- noted in countries that have their own national to- ventions and policies. Failure to do so will likely bacco-control policies. For example, the Family lead to a surge in smoking-related morbidity and Smoking Prevention and Tobacco Control Act in mortality that could have been prevented otherwise.

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