Significance of smoking machine toxicant yields to blood-level exposure in water pipe tobacco smokers

Biomarkers of Waterpipe Tobacco Smoke Exposure: A Systematic Review and Meta-Analysis

INTRODUCTION

The prevalence of waterpipe tobacco smoking is increasing globally. Biomarkers of waterpipe tobacco smoke (WTS) exposure are less studied.

AIMS AND METHODS

To identify the types of biomarkers of WTS exposure and estimate changes in biomarker concentrations pre- to post-WTS exposure. PubMed, Embase, Web of Science, CINAHL Plus, PsycINFO, and Cochrane Library were searched for studies up to April 24, 2023. The types of biomarkers were identified. Random-effects models were used to estimate changes in biomarker concentrations pre- to post-WTS exposure.

RESULTS

Seventy-three studies involving 3755 participants exposed to WTS (49% male, mean age: 24.8 years) and 11 types of biomarkers of WTS exposure were identified. The biomarkers included tobacco alkaloids, expired carbon monoxide (eCO), carboxyhemoglobin (COHb), tobacco-specific nitrosamines, volatile organic compounds (VOCs), polycyclic aromatic hydrocarbons (PAHs), heavy metals, unmetabolized VOCs, unmetabolized PAHs, furan metabolites, and heterocyclic aromatic amines. Compared with pre-WTS exposure, eCO (breath; mean difference [MD] 27.00 ppm; 95% confidence interval [CI]: 20.91 to 33.08), COHb (blood; MD 4.30%; 95%CI: 2.57 to 6.03), COHb (breath; MD 7.14%; 95%CI: 4.96 to 9.31), nicotine (blood; MD 8.23 ng/mL; 95%CI: 6.27 to 10.19), and cotinine (urine; MD 110.40 ng/mL; 95%CI: 46.26 to 174.54) significantly increased post-WTS exposure.

CONCLUSIONS

Biomarkers of WTS exposure were systematically identified. The similarity between the biomarkers of WTS exposure and those of cigarette smoke and higher concentrations of some biomarkers post-WTS exposure underscore the need for further research on applying biomarkers in surveillance, interventions, and regulations to mitigate the harms of waterpipe tobacco smoking.

IMPLICATIONS

This study provides the first comprehensive overview of biomarkers investigated and available for assessing WTS exposure and their concentration changes in the human body. Researchers can use biomarkers such as eCO, COHb, nicotine, and cotinine to measure the health risks associated with WTS exposure and objectively evaluate the effectiveness of public health interventions aimed at reducing waterpipe tobacco smoking. Public health policymaking can also be informed through increased biomarker concentrations following WTS exposure, to implement regulations and public health education campaigns on limiting or preventing waterpipe tobacco smoking.

Comparison of emissions across tobacco products: A slippery slope in tobacco control

In this narrative review, we highlight the challenges of comparing emissions from different tobacco products under controlled laboratory settings (using smoking/vaping machines). We focus on tobacco products that generate inhalable smoke or aerosol, such as cigarettes, cigars, hookah, electronic cigarettes, and heated tobacco products. We discuss challenges associated with sample generation including variability of smoking/vaping machines, lack of standardized adaptors that connect smoking/vaping machines to different tobacco products, puffing protocols that are not representative of actual use, and sample generation session length (minutes or number of puffs) that depends on product characteristics. We also discuss the challenges of physically characterizing and trapping emissions from products with different aerosol characteristics. Challenges to analytical method development are also covered, highlighting matrix effects, order of magnitude differences in analyte levels, and the necessity of tailored quality control/quality assurance measures. The review highlights two approaches in selecting emissions to monitor across products, one focusing on toxicants that were detected and quantified with optimized methods for combustible cigarettes, and the other looking for product-specific toxicants using non-targeted analysis. The challenges of data reporting and statistical analysis that allow meaningful comparison across products are also discussed. We end the review by highlighting that even if the technical challenges are overcome, emission comparison may obscure the absolute exposure from novel products if we only focus on relative exposure compared to combustible products.

Nontargeted Analysis in Tobacco Research: Challenges and Opportunities

Tobacco products are evolving at a pace that has outstripped tobacco control, leading to a high prevalence of tobacco use in the population. Researchers have been tirelessly developing suitable techniques to assess these products' emissions, toxicity, and public health impact. The nonclinical testing of tobacco products to assess the chemical profile of emissions is needed for evidence-based regulations. This testing has largely relied on targeted analytical methods that focus on constituent lists that may fall short in determining the toxicity of newly designed tobacco products. Nontargeted analysis (NTA), or the process of identifying and quantifying compounds within a complex matrix without prior knowledge of its chemical composition, is a promising technique for tobacco regulation, but it is not without challenges. The lack of standardized methods for sample generation, sample preparation, chromatographic separation, compound identification, and data analysis and reporting must be addressed so that the quality and reproducibility of the data generated by NTA can be benchmarked. This review discusses the challenges and highlights the opportunities of NTA in studying tobacco product constituents and emissions.

Impact of smoking intensity and device cleaning on IQOS emissions: comparison with an array of cigarettes

SIGNIFICANCE

IQOS is a heated tobacco product that has been widely advertised by Philip Morris International (PMI) as a reduced-exposure product compared with cigarettes. Reduced exposure results from reduced emission of toxicants which could be influenced by product constituents and user behaviour. This study aims to assess the influence of user behaviour, including device cleaning and puffing parameters, on toxicant emissions from IQOS.

METHODS

IQOS aerosols were generated by a smoking machine using the combination of two cleaning protocols (after 1 stick vs 20 sticks) and five puffing regimes (including standard cigarette puffing regimes and IQOS-tailored regimes). The generated aerosols were analysed by targeted methods for phenol and carbonyl quantification, and by chemical screening for the identification of unknown compounds.

RESULTS

Puffing parameters significantly affected phenol and carbonyl emissions while device cleaning had no effect. Harsher puffing conditions like more, longer, and larger puffs yielded higher levels for most toxicant emissions. Comparing the obtained data with data reported by PMI on 50 cigarette brands smoked under different puffing regimes showed various trends for phenol and carbonyl emissions, with IQOS emissions sometimes higher than cigarettes. Also, the chemical screening resulted in the tentative identification of ~100 compounds in the IQOS aerosols (most of limited toxicity data).

CONCLUSION

This study showed that puffing parameters, but not device cleaning, have significant effects on carbonyl, phenol and other emissions. Data analysis highlighted the importance of comparing IQOS emissions with an array of commercial cigarettes tested under different puffing regimes before accepting reduced exposure claims.

Water Pipe (Hookah) Smoking and Cardiovascular Disease Risk: A Scientific Statement From the American Heart Association

Tobacco smoking with a water pipe or hookah is increasing globally. There are millions of water pipe tobacco smokers worldwide, and in the United States, water pipe use is more common among youth and young adults than among adults. The spread of water pipe tobacco smoking has been abetted by the marketing of flavored tobacco, a social media environment that promotes water pipe smoking, and misperceptions about the addictive potential and potential adverse health effects of this form of tobacco use. There is growing evidence that water pipe tobacco smoking affects heart rate, blood pressure regulation, baroreflex sensitivity, tissue oxygenation, and vascular function over the short term. Long-term water pipe use is associated with increased risk of coronary artery disease. Several harmful or potentially harmful substances present in cigarette smoke are also present in water pipe smoke, often at levels exceeding those found in cigarette smoke. Water pipe tobacco smokers have a higher risk of initiation of cigarette smoking than never smokers. Future studies that focus on the long-term adverse health effects of intermittent water pipe tobacco use are critical to strengthen the evidence base and to inform the regulation of water pipe products and use. The objectives of this statement are to describe the design and operation of water pipes and their use patterns, to identify harmful and potentially harmful constituents in water pipe smoke, to document the cardiovascular risks of water pipe use, to review current approaches to water pipe smoking cessation, and to offer guidance to healthcare providers for the identification and treatment of individuals who smoke tobacco using water pipes.

Construction and validation of the water pipe harm perception scale (WHPS-6) among the Lebanese population

Compared to cigarettes, water pipe is misconceived as being less addictive and containing less nicotine. This study aimed at constructing and validating a water pipe harm perception scale among a sample of the Lebanese population. A cross-sectional study was carried out between February and December 2017 using a proportionate cluster sample of Lebanese adults (492 participants). The water pipe harm scale items converged over a solution of one factor that had an eigenvalue over 1, explaining a total of 66.75% of the variance. The model used was adequate (Kaiser-Meyer-Olkin measure = 0.862 and Bartlett's test of sphericity p < 0.001). The reliability of all scale's items was high (Cronbach's alpha = 0.896). Higher cigarette dependence (LCD score) was significantly associated with higher water pipe harm perception scores, whereas exclusive water pipe smokers (Beta = - 2.142) and dual water pipe and cigarette smokers (Beta = -2.142) compared to nonsmokers, as well as those with high monthly income compared to a low one (Beta = -0.614), were significantly associated with lower water pipe harm perception scores. We constructed the first scale for measuring water pipe harm perception: the WHPS-6. The results of the present study demonstrate that the WHPS-6 can be used in clinical practice and research to assess the harm perception induced by water pipe smoking.

Answering questions about electronic cigarettes using a multidisciplinary model

Electronic cigarettes (ECIGs) are a relatively new class of tobacco products and a subject of much debate for scientists and policymakers worldwide. Objective data that address the ECIG risk-benefit ratio for individual and public health are needed, and addressing this need requires a multidisciplinary approach that spans several areas of psychology as well as chemistry, toxicant inhalation, and physiology. This multidisciplinary approach would benefit from methods that are reliable, valid, and swift. For this reason, we formed a multidisciplinary team to develop methods that could answer questions about ECIGs and other potential modified risk tobacco products. Our team includes scientists with expertise in psychology (clinical, community, and experimental) and other disciplines, including aerosol research, analytical chemistry, biostatistics, engineering, internal medicine, and public health. The psychologists on our team keep other members focused on factors that influence individual behavior, and other team members keep the psychologists aware of other issues, such as product design. Critically, all team members are willing to extend their interests beyond the boundaries of their discipline to collaborate effectively with the shared goal of producing the rigorous science needed to inform empirically based tobacco policy. In addition, our trainees gain valuable knowledge from these collaborations and learn that other disciplines are accessible, exciting, and can enhance their own research. Multidisciplinary work presents challenges: learning other scientists' languages and staying focused on our core mission. Overall, our multidisciplinary team has led to several major findings that inform the scientific, regulatory, and public health communities about ECIGs and their effects. (PsycINFO Database Record (c) 2019 APA, all rights reserved).

Serum VEGF Level Is Different in Adolescents Smoking Waterpipe versus Cigarettes: The Irbid TRY

Waterpipe (Wp) use is associated with most devastating diseases and particularly popular among adolescents. Vascular endothelium growth factor (VEGF) is essential for generating new vessels. The effect of smoking tobacco on VEGF is controversial and unknown among adolescents. Therefore, the current study compared serum VEGF in adolescents smoking cigarettes (Cg) only (9.3%), Wp only (19.6%), and dual (Wp and Cg) (36.4%) versus nonsmokers (34.6%) in adolescents. A self-reported questionnaire and enzyme-linked immunosorbent assay (ELISA) were used to obtain smoking status and serum VEGF, respectively, in 475 (age: 14.6 ± 1.0 years) boys (n = 263) and girls (n = 212) from Irbid, Jordan. The analysis showed that smoking status (R² = 0.021; p = 0.001) and gender (R² = 0.035; p = 0.000) can predict VEGF. Furthermore, 2-way-ANCOVA revealed that VEGF was lower in the dual cohort versus the Cg (33.4%; p = 0.04) and nonsmoker (29.6%; p = 0.003) cohorts; VEGF in smokers, was lower (33.6%; p = 0.04) in the Wp versus nonsmokers in the boys but not the girls. These results are unique and suggest that smoking lowers VEGF, which might adversely affect vascular growth and function. This is alarming given that adolescents are still in the development stage and smoking, particularly Wp, is popular among them. Therefore, interventions targeting smoking among schoolchildren are urgently needed to avoid the negative effects of smoking, especially on vascular health.

Waterpipe Smoking Is Associated with Changes in Fibrinogen, FVII, and FVIII Levels

Cigarette smoking has been shown to be associated with changes in coagulation factors in the circulation and the subsequent thrombosis development. In this study, the impact of waterpipe smoking on the levels of fibrinogen, factor VII (FVII), and factor VIII (FVIII) was investigated. In addition, the effects of waterpipe smoking were compared to those of cigarette smoking and never smokers. A total of 80 male smokers (40 cigarette smokers and 40 waterpipe smokers) and 40 apparently healthy never smokers were recruited in the study. Both waterpipe smoking and cigarette smoking induced significant increases in the plasma levels of fibrinogen, factor VII, and factor VIII (p < 0.01). The magnitude of the increase in fibrinogen levels induced by waterpipe smoking was higher than that induced by cigarette smoking (p < 0.01), while similar increases were observed in other factors (p > 0.05). In addition, in the waterpipe group, the magnitude of the increase in fibrinogen and factor VIII was higher in the smokers with more than 3 years of use (p < 0.05). In conclusion, similar to cigarette smoking, waterpipe smoking modulates the levels of coagulation factors, suggesting its thrombotic potential.

Cigarette Filter Ventilation and Smoking Protocol Influence Aldehyde Smoke Yields

The WHO study group on tobacco product regulation (TobReg) advised regulating and lowering toxicant levels in cigarette smoke. Aldehydes are one of the chemical classes on the TobReg smoke toxicants priority list. To provide insight in factors determining aldehyde yields, the levels of 12 aldehydes in mainstream cigarette smoke of 11 Dutch brands were quantified. Variations in smoking behavior and cigarette design affecting human exposure to aldehydes were studied by using four different machine testing protocols. Machine smoking was based on the International Standardization Organization (ISO) and Health Canada Intense (HCI) regime, both with and without taping the filter vents. The 11 cigarette brands differed in (i) design and blend characteristics; (ii) tar, nicotine, and carbon monoxide (TNCO) levels; (iii) popularity; and (iv) manufacturer. Cigarette smoke was trapped on a Cambridge filter pad and carboxen cartridge. After being dissolved in methanol/CS2 and derivatization with DNPH, the aldehyde yields were determined using HPLC-DAD. Using an intense smoking regime (increased puff volume, shorter puff interval) significantly increased aldehyde yields, following the pattern: ISO < ISO-taped < HCI-untaped < HCI. For all of the regimes, acetaldehyde and acrolein yields were strongly correlated ( r = 0.804). The difference in TNCO and aldehyde levels between regular and highly ventilated low-TNCO cigarettes (as measured using ISO) diminished when smoking intensely; this effect is stronger when combined with taping filter vents. The highly ventilated low-TNCO brands showed six times more aldehyde production per mg nicotine for the intense smoking regimes. In conclusion, acetaldehyde and acrolein can be used as representatives for the class of volatile aldehydes for the different brands and smoking regimes. The aldehyde-to-nicotine ratio increased when highly ventilated cigarettes were smoked intensely, similar to real smokers. Thus, a smoker of highly ventilated low-TNCO cigarettes has an increased potential for higher aldehyde exposures compared to a smoker of regular cigarettes.

Toxicant inhalation among singleton waterpipe tobacco users in natural settings

BACKGROUND

Studies that assess waterpipe tobacco smoking behaviour and toxicant exposure generally use controlled laboratory environments with small samples that may not fully capture real-world variability in human behaviour and waterpipe products. This study aimed to conduct real-time sampling of waterpipe tobacco use in natural environments using an in situ device.

METHODS

We used the REALTIME sampling instrument: a validated, portable, self-powered device designed to sample automatically a fixed percentage of the aerosol flowing through the waterpipe mouthpiece during every puff. We recruited participants at café and home settings in Jordan and measured puffing behaviour in addition to inhalation exposure of total particulate matter (TPM), carbon monoxide (CO), nicotine, polycyclic aromatic hydrocarbons and volatile aldehydes. We correlated total inhaled volume with five selected toxicants and calculated the regression line of this relationship.

RESULTS

Averaged across 79 singleton sessions (52% male, mean age 27.0, 95% home sessions), sessions lasted 46.9 min and participants drew 290 puffs and inhaled 214 L per session. Mean quantities of inhaled toxicants per session were 1910 mg TPM, 259 mg CO, 5.0 mg nicotine, 117 ng benzo[a]pyrene and 198 ng formaldehyde. We found positive correlations between total inhaled volume and TPM (r=0.472; p<0.001), CO (r=0.751; p<0.001), nicotine (r=0.301, p=0.035) and formaldehyde (r=0.526; p<0.001), but a non-significant correlation for benzo[a]pyrene (r=0.289; p=0.056).

CONCLUSIONS

In the natural environment, waterpipe tobacco users inhale large quantities of toxicants that induce tobacco-related disease, including cancer. Toxicant content per waterpipe session is at least equal, but for many toxicants several magnitudes of order higher, than that of a cigarette. Health warnings based on early controlled laboratory studies were well founded; if anything our findings suggest a greater exposure risk.

Hookah smoking impairs nasal mucociliary clearance

INTRODUCTION

Active tobacco smoking has been causally associated with nasal mucociliary clearance (MCC). Smoking through a hookah as an alternative to tobacco smoking has been shown in some scientific studies to have several toxic effects on human health. However, no study has been conducted on the effects on nasal MCC of the hookah as an alternative way of smoking tobacco. The aim of this study is to research whether or not hookah affects nasal MCC.

METHODS

The study included 40 subjects in the control group and 38 subjects in the hookah group. The hookah group was divided into two subgroups: those who used hookahs regularly, once every week (N1 group), and those who used hookahs more than once a week (N2 group, of 2 to 5 sessions/week). The N1 group had 20 subjects, while the N2 group had 18 subjects. The MCC test was performed on each subject and results were recorded in minutes.

RESULTS

The nasal MCC value in the total hookah group was found to be significantly higher than in the control group (p<0.05). The nasal MCC value of the N2 group that used hookahs more than once a week was significantly higher than those of the control group and N1 group that used hookahs once every week (p<0.05).

CONCLUSIONS

Our study has shown that, especially when a hookah was used more than once a week, there was MCC impairment that may put the participant at risk of respiratory tract diseases.

Health Effects of Waterpipe Tobacco Use: Getting the Public Health Message Just Right

Many public health messages benchmark the harms of waterpipe tobacco against those of cigarettes, usually using numerical magnitudes of risk. This approach, although well intentioned, could be perceived as alarmist, damaging scientific credibility, and giving an unintended impression that one tobacco product is less harmful than the other. This commentary makes clear the harm waterpipe tobacco smoking poses to public health by describing its mechanism of use, consumption uptake, toxicologic profile, and documented health outcomes, as well as challenge existing thinking that toxicologic assessments are the most appropriate way to frame waterpipe tobacco health promotion messages. How can we describe the health effects of waterpipe tobacco without undermining its toxicity nor falling into the temptation of alarmist messaging? Several recommendations are provided.

Increasing popularity of waterpipe tobacco smoking and electronic cigarette use: Implications for oral healthcare

Cigarette smoking increases the risk of developing several systemic conditions including cancer, cardiovascular and pulmonary diseases. Cigarette smoking is also detrimental to oral health as it increases the incidence and severity of oral cancer, periodontal diseases and peri-implantitis, as well as impacting negatively on the dental patients' response to therapy. Therefore, consideration of smoking behavior and recommendation of smoking cessation are important parts of dental treatment planning. However, cigarettes are no longer the most popular form of tobacco use among adolescents in the United States and globally. In recent years, tobacco smoking using a waterpipe ("hookah," "shisha") and use of electronic cigarettes (ECIGs) has increased significantly. Thus, dental clinicians likely will treat more patients who are waterpipe and/or ECIG users. Yet, the literature on the health effects of waterpipe and ECIGs use is sparse. Both waterpipe and ECIGs deliver the dependence-producing drug nicotine. Waterpipe tobacco smoking has been associated with periodontitis, dry socket, premalignant lesions, and oral and esophageal cancer. The health effects of long-term ECIG use are unknown. The purpose of this review is to inform healthcare professionals about waterpipes and ECIGs, highlight emerging evidence on the biological effects of these increasingly popular tobacco products, and introduce perspectives for dental patient management and future research.

The Influence of a Mouthpiece-Based Topography Measurement Device on Electronic Cigarette User's Plasma Nicotine Concentration, Heart Rate, and Subjective Effects Under Directed and Ad Libitum Use Conditions

INTRODUCTION

Electronic cigarettes e-cigarettes aerosolize a liquid solution often containing nicotine. e-cigarette nicotine delivery may be influenced by user puffing behaviors ("puff topography"). E-cigarette puff topography can be recorded using mouthpiece-based computerized systems. The present study sought to examine the extent to which these systems influence e-cigarette nicotine delivery and other e-cigarette associated acute effects under ad libitum use conditions.

METHODS

Plasma nicotine concentration, heart rate, and subjective effects were assessed in 29 experienced e-cigarette users using their preferred e-cigarette battery and liquid (≥12mg/mL nicotine) in two sessions differing only by the presence of a mouthpiece-based device. In both sessions, participants completed a directed e-cigarette use bout (10 puffs, 30-s interpuff interval) and a 90-min ad libitum bout. Puff topography was recorded in the session with the topography mouthpiece.

RESULTS

Plasma nicotine, heart rate, and subjective effects, aside from "Did the e-cigarette Taste Good?" were independent of topography measurement (higher mean taste ratings were observed in the no topography condition). Mean (SEM) plasma nicotine concentration following the ad libitum bout was 34.3ng/mL (4.9) in the no topography condition and 35.7ng/mL (4.3) in the topography condition. Longer puff durations, longer interpuff intervals, and larger puff volumes were observed in the ad libitum relative to the directed bout.

CONCLUSIONS

E-cigarette use significantly increased plasma nicotine concentration and heart rate while suppressing abstinence symptoms. These effects did not differ when a topography mouthpiece was present. Future studies using ad libitum e-cigarette use bouts would facilitate understanding of e-cigarette toxicant yield.

IMPLICATIONS

No prior study has examined whether mouthpiece-based topography recording devices influence e-cigarette associated nicotine delivery, heart rate, or subjective effects under ad libitum conditions or assessed ad libitum puff topography in experienced individuals using their preferred e-cigarette battery and liquid with a mouthpiece-based computerized device. E-cigarette use significantly increased plasma nicotine concentration and heart rate while suppressing abstinence symptoms. These effects did not differ when a topography mouthpiece was present. Ad libitum puff topography differed from puff topography recorded during directed puffing. These findings suggest that future studies using ad libitum use bouts would facilitate better understanding of e-cigarette toxicant yield.

Hookah Use Among Florida High School Students, 2011-2014

INTRODUCTION

Adolescent use of hookah continues to increase in the U.S., even in states that have reported decreases in traditional cigarette use among youth. Hookah use typically involves smoking a moistened, loose, sweetened tobacco product with charcoal as the heat source.

METHODS

Data from the 2011-2014 Florida Youth Tobacco Survey were analyzed in 2016 to determine trends in the prevalence of lifetime hookah use (at least once in the adolescent's lifetime) and current hookah use (used in the past 30 days) among high school students (grades 9-12).

RESULTS

In 2014, a total of 22.5% of Florida public high school students reported ever smoking a hookah, up from 18.2% in 2011. Current hookah use was reported by 11.6% of high school students, an increase from 8.0% in 2011. Female high school students had an increase in use whereas male students' prevalence was relatively stable. Hispanic and non-Hispanic black students reported significant increases over time.

CONCLUSIONS

The increase in hookah use among adolescents needs continuous monitoring given the recent increase after relatively stable patterns. Efforts are needed to reduce the appeal and use of hookah by young people.

Group Waterpipe Tobacco Smoking Increases Smoke Toxicant Concentration

INTRODUCTION

Waterpipe tobacco smoking is a global health concern. Laboratory research has focused on individual waterpipe users while group use is common. This study examined user toxicant exposure and smoke toxicant yield associated with individual and group waterpipe smoking.

METHODS

Twenty-two pairs of waterpipe smokers used a waterpipe individually and as a dyad. Before and after smoking, blood was sampled and expired carbon monoxide (CO) measured; puff topography was recorded throughout. One participant from each pair was selected randomly and their plasma nicotine and expired air CO concentrations were compared when smoking alone to when smoking as part of a dyad. Recorded puff topography was used to machine-produce smoke that was analyzed for toxicant content.

RESULTS

There was no difference in mean plasma nicotine concentration when an individual smoked as part of a dyad (mean = 14.9 ng/ml; standard error of the mean [SEM] = 3.0) compared to when smoking alone (mean = 10.0 ng/ml; SEM = 1.5). An individual smoking as part of as a dyad had, on average, lower CO (mean = 15.8 ppm; SEM = 2.0) compared to when smoking alone (mean= 21.3 ppm; SEM = 2.7). When two participants smoked as a dyad they took, on average, more puffs (mean = 109.8; SEM = 7.6) than a singleton smoker (mean = 77.7; SEM = 8.1) and a shorter interpuff interval (IPI; dyad mean = 23.8 seconds; SEM = 1.9; singleton mean = 40.8 seconds; SEM = 4.8). Higher concentrations of several toxicants were observed in dyad-produced smoke.

DISCUSSION

Dyad smoking may increase smoke toxicant content, likely due to the dyad's shorter IPIs and greater puff number. More work is needed to understand if group waterpipe smoking alters the health risks of waterpipe tobacco smoking.

IMPLICATIONS

This study is the first to measure toxicants in smoke generated from a waterpipe when used by a dyad. Relative to smoke generated by a singleton, dyad smoke had higher concentration of some toxicants. These differences may be attributed to differences in puffing behavior, specifically the shorter IPI and greater puff number observed in the dyad condition. Relative to singleton smokers, dyad smokers were exposed to less CO, but nicotine exposure did not differ. More work is needed to assess the health effects of inhalation of more toxicant-laden smoke during group waterpipe use.

Systematic Review and Meta-Analysis of Inhaled Toxicants from Waterpipe and Cigarette Smoking

OBJECTIVE

Waterpipe tobacco smoking (WTS) is an emerging trend worldwide. To inform public health policy and educational programming, we systematically reviewed the biomedical literature to compute the inhaled smoke volume, nicotine, tar, and carbon monoxide (CO) associated with a single WTS session and a single cigarette.

METHODS

We searched seven biomedical bibliographic databases for controlled laboratory or natural environment studies designed to mimic human tobacco consumption. Included studies quantified the mainstream smoke of a single cigarette and/or single WTS session for smoke volume, nicotine, tar, and/or CO. We conducted meta-analyses to calculate summary estimates for the inhalation of each unique substance for each mode of tobacco consumption. We assessed between-study heterogeneity using chi-squared and I-squared statistics.

RESULTS

Sufficient data from 17 studies were available to derive pooled estimates for inhalation of each exposure via each smoking method. Two researchers working independently abstracted measurement of smoke volume in liters, and nicotine, tar, and CO in milligrams. All numbers included in meta-analyses matched precisely between the two researchers (100% agreement, Cohen's k=1.00). Whereas one WTS session was associated with 74.1 liters of smoke inhalation (95% confidence interval [CI] 38.2, 110.0), one cigarette was associated with 0.6 liters of smoke (95% CI 0.5, 0.7). One WTS session was also associated with higher levels of nicotine, tar, and CO.

CONCLUSIONS

One WTS session consistently exposed users to larger smoke volumes and higher levels of tobacco toxicants compared with one cigarette. These computed estimates may be valuable to emphasize in prevention programming.

Waterpipe tobacco smoking: A new smoking epidemic among the young?

Waterpipe (hookah, narghile) tobacco smoking (WTS) is becoming prevalent worldwide and is one of the most popular forms of tobacco use among youth. WTS prevalence has increased dramatically among youth in the United States within the past decade. Misperceived as less harmful than cigarette smoking, WTS is associated with many of the same chronic health effects such as lung cancer, chronic obstructive pulmonary disease, cardiovascular disease, bronchitis, and asthma. Much of this risk is due to the fact that a single WTS session exposes users to large volumes of smoke that contain toxic chemicals such as carbon monoxide, cancer-causing polycyclic aromatic hydrocarbons, and volatile aldehydes. Unlike cigarette smoking, WTS poses unique risks of acute negative health outcomes including carbon monoxide poisoning and the spread of communicable diseases such as herpes and tuberculosis. Because waterpipe tobacco smoke contains the addictive chemical nicotine, youth who smoke tobacco from a waterpipe may be at risk for dependence. As a result, many youth may initiate WTS and continue to use despite negative health effects. Considering many of the potential negative health effects associated with WTS affect the pulmonary system, pulmonologists and primary care providers may treat patients who are waterpipe tobacco smokers and should be aware of the risk associated with WTS. The purpose of this review is to describe a waterpipe, the prevalence and correlates of WTS, the toxicants found in waterpipe tobacco smoke, the health effects of WTS, and implications for pulmonologists and other clinicians.

Design and Validation of a Research-Grade Waterpipe Equipped With Puff Topography Analyzer

INTRODUCTION

Worldwide, commercially available waterpipes vary widely in design and durability, including differences in fabrication materials, degree of leak-tight fit, and flow path diameter. Little is known about how the components of the waterpipe may influence puffing behavior and user's exposure to toxins. To systematically evaluate exposure, it is necessary to use a standardized research-grade waterpipe (RWP) when conducting clinical and laboratory-based trials.

METHODS

We developed a RWP that is configured with an in-line topography system which allows real-time measurement and recording of the smoke volume drawn through the RWP. The RWP was calibrated across the flow rate range expected for waterpipe tobacco smoking and the calibration was verified for known puff volumes using a smoking machine. Operation of the RWP was qualified in a cohort of experienced waterpipe smokers, each smoker using the RWP ad libitum in a laboratory setting while smoker topography and subjective effects data were collected.

RESULTS

RWP machine smoking was highly reproducible and yielded puff volumes that agreed well with true values. User acceptance was comparable, and puffing behavior was similar in pattern, with more frequent puffing in the beginning of the session, but significantly different in intensity from that used to estimate the majority of toxicant exposure reported in the literature.

CONCLUSIONS

The RWP operates with known precision and accuracy and is well accepted by experienced smokers. This tool can be used to determine the extent to which puffing behaviors are affected by the waterpipe design, components, and/or accessories, tobacco nicotine content, sweet flavorings and/or additives known to increase addictiveness.

IMPLICATIONS

This study describes a standardized RWP, equipped with a puffing topography analyzer, which can operate with known precision and accuracy, and is well-accepted by experienced smokers in terms of satisfaction and reward. The RWP is an important tool for determining if puffing behaviors, and thus estimated toxin exposures, are affected by the waterpipe design, components, and/or accessories, tobacco nicotine content, sweet flavorings, and/or additives that are known to increase addictiveness.

Waterpipe Smoking and Regulation in the United States: A Comprehensive Review of the Literature

BACKGROUND

Researchers in tobacco control are concerned about the increasing prevalence of waterpipe smoking in the United States, which may pose similar risks as cigarette smoking. This review explores the prevalence of waterpipe smoking in the United States as well as the shortcomings of current U.S. policy for waterpipe control and regulation.

METHODS

Researchers conducted a literature review for waterpipe articles dated between 2004 and 2015 using five online databases: MEDLINE, CINHAHL, ScienceDirect, PMC, and Cochrane Library.

RESULTS

To date, few studies have explored the marketing and regulation of waterpipe smoking in the U.S., which has increased in the last ten years, especially among women, adolescents, and young adults. Data indicate that the majority of waterpipe smokers are unaware of the potential risks of use. In addition, current tobacco control policies do not address waterpipe smoking, enabling tobacco companies to readily market and sell waterpipe products to young adults, who are at risk for becoming lifelong smokers.

CONCLUSION

Policy makers in the area of public health need to update existing tobacco regulations to include waterpipe smoking. Similarly, public health researchers should develop public health campaigns and interventions to address the increasing rates of waterpipe smoking in the United States.

Toxicant content, physical properties and biological activity of waterpipe tobacco smoke and its tobacco-free alternatives

OBJECTIVES

Waterpipe smoking using sweetened, flavoured tobacco products has become a widespread global phenomenon. In this paper, we review chemical, physical and biological properties of waterpipe smoke.

DATA SOURCES

Peer-reviewed publications indexed in major databases between 1991 and 2014. Search keywords included a combination of: waterpipe, narghile, hookah, shisha along with names of chemical compounds and classes of compounds, in addition to terms commonly used in cellular biology and aerosol sizing.

STUDY SELECTION

The search was limited to articles published in English which reported novel data on waterpipe tobacco smoke (WTS) toxicant content, biological activity or particle size and which met various criteria for analytical rigour including: method specificity and selectivity, precision, accuracy and recovery, linearity, range, and stability.

DATA EXTRACTION

Multiple researchers reviewed the reports and collectively agreed on which data were pertinent for inclusion.

DATA SYNTHESIS

Waterpipe smoke contains significant concentrations of toxicants thought to cause dependence, heart disease, lung disease and cancer in cigarette smokers, and includes 27 known or suspected carcinogens. Waterpipe smoke is a respirable aerosol that induces cellular responses associated with pulmonary and arterial diseases. Except nicotine, smoke generated using tobacco-free preparations marketed for 'health conscious' users contains the same or greater doses of toxicants, with the same cellular effects as conventional products. Toxicant yield data from the analytical laboratory are consistent with studies of exposure biomarkers in waterpipe users.

CONCLUSIONS

A sufficient evidence base exists to support public health interventions that highlight the fact that WTS presents a serious inhalation hazard.

NIH electronic cigarette workshop: developing a research agenda

BACKGROUND

Electronic cigarettes (e-cigarettes) represent an emerging public health issue. These devices deliver nicotine along with other constituents, including flavorants, via an inhalable aerosol. Their uptake is rapidly increasing in both adults and youths, primarily among current smokers. Public debate is increasing on how these devices should be regulated and used, yet only limited peer-reviewed research exists. To develop a informed policy for e-cigarettes, their effects on human behavior, physiology, and health need to be understood.

PURPOSE

This paper describes proceedings from a National Institutes of Health-sponsored workshop, which was held in November 2013, to identify research needs related to the effects of e-cigarettes. Discussion topics included e-cigarette risks and abuse potential; the potential role for e-cigarettes in harm reduction and smoking cessation; unintended consequences of e-cigarette use, such as becoming a gateway to conventional cigarettes; and dual use of both e-cigarettes and conventional cigarettes.

RESULTS AND CONCLUSIONS

The research needs identified by the workshop participants included the following: standards to measure the contents and emissions of e-cigarettes; biomarkers of exposure; physiological effects of e-cigarettes on tissues and organ systems, including pulmonary and cardiovascular; information on e-cigarette users, how the devices are used, and identification of the best tools to assess these measures; factors that drive use and influence patterns of use; and appropriate methods for evaluating a potential role for e-cigarettes in smoking or nicotine cessation. To understand fully the challenges and the opportunities that e-cigarettes represent, expertise will be needed in basic, behavioral, translational, and clinical sciences.

Preliminary results of an examination of electronic cigarette user puff topography: the effect of a mouthpiece-based topography measurement device on plasma nicotine and subjective effects

INTRODUCTION

Electronic cigarettes (ECIGs) heat a nicotine-containing solution; the resulting aerosol is inhaled by the user. Nicotine delivery may be affected by users' puffing behavior (puff topography), and little is known about the puff topography of ECIG users. Puff topography can be measured using mouthpiece-based computerized systems. However, the extent to which a mouthpiece influences nicotine delivery and subjective effects in ECIG users is unknown.

METHODS

Plasma nicotine concentration, heart rate, and subjective effects were measured in 13 experienced ECIG users who used their preferred ECIG and liquid (≥ 12 mg/ml nicotine) during 2 sessions (with or without a mouthpiece). In both sessions, participants completed an ECIG use session in which they were instructed to take 10 puffs with 30-second inter-puff intervals. Puff topography was recorded in the mouthpiece condition.

RESULTS

Almost all measures of the effects of ECIG use were independent of topography measurement. Collapsed across session, mean plasma nicotine concentration increased by 16.8 ng/ml, and mean heart rate increased by 8.5 bpm (ps < .05). Withdrawal symptoms decreased significantly after ECIG use. Participants reported that the mouthpiece affected awareness and made ECIG use more difficult. Relative to previously reported data for tobacco cigarette smokers using similar topography measurement equipment, ECIG-using participants took larger and longer puffs with lower flow rates.

CONCLUSIONS

In experienced ECIG users, measuring ECIG topography did not influence ECIG-associated nicotine delivery or most measures of withdrawal suppression. Topography measurement systems will need to account for the low flow rates observed for ECIG users.

Effects of user puff topography, device voltage, and liquid nicotine concentration on electronic cigarette nicotine yield: measurements and model predictions

INTRODUCTION

Some electronic cigarette (ECIG) users attain tobacco cigarette-like plasma nicotine concentrations while others do not. Understanding the factors that influence ECIG aerosol nicotine delivery is relevant to regulation, including product labeling and abuse liability. These factors may include user puff topography, ECIG liquid composition, and ECIG design features. This study addresses how these factors can influence ECIG nicotine yield.

METHODS

Aerosols were machine generated with 1 type of ECIG cartridge (V4L CoolCart) using 5 distinct puff profiles representing a tobacco cigarette smoker (2-s puff duration, 33-ml/s puff velocity), a slow average ECIG user (4 s, 17 ml/s), a fast average user (4 s, 33 ml/s), a slow extreme user (8 s, 17 ml/s), and a fast extreme user (8 s, 33 ml/s). Output voltage (3.3-5.2 V or 3.0-7.5 W) and e-liquid nicotine concentration (18-36 mg/ml labeled concentration) were varied. A theoretical model was also developed to simulate the ECIG aerosol production process and to provide insight into the empirical observations.

RESULTS

Nicotine yields from 15 puffs varied by more than 50-fold across conditions. Experienced ECIG user profiles (longer puffs) resulted in higher nicotine yields relative to the tobacco smoker (shorter puffs). Puff velocity had no effect on nicotine yield. Higher nicotine concentration and higher voltages resulted in higher nicotine yields. These results were predicted well by the theoretical model (R (2) = 0.99).

CONCLUSIONS

Depending on puff conditions and product features, 15 puffs from an ECIG can provide far less or far more nicotine than a single tobacco cigarette. ECIG emissions can be predicted using physical principles, with knowledge of puff topography and a few ECIG device design parameters.

Electronic cigarette effectiveness and abuse liability: predicting and regulating nicotine flux

Electronic cigarettes (ECIGs) comprise an aerosolized nicotine delivery product category that provides consumers with probably unprecedented control over extensive features and operating conditions, allowing a wide range of nicotine yields to be obtained. Depending on the combination of such ECIG variables as electrical power input, geometry, liquid composition, and puff behavior, ECIG users can extract in a few puffs far more or far less nicotine than with a conventional combustible cigarette. These features of ECIG design and use present challenges for public health policy, central among which is the question of how to regulate nicotine delivery. In this commentary, we propose a conceptual framework intended to provide a convenient approach for evaluating and regulating the nicotine emitted from ECIGs. This framework employs nicotine flux to account for the total dose and rate at which nicotine reaches the user, 2 key factors in drug abuse liability. The nicotine flux is the nicotine emitted per puff second (e.g., mg/s) by a given ECIG design under given use conditions, and it can be predicted accurately using physical principles. We speculate that if the flux is too low, users likely will abandon the device and maintain conventional tobacco product use. Also, we speculate that if the flux is too high, individuals may suffer toxic side effects and/or the device may have higher-than-necessary abuse liability. By considering ECIG design, operation conditions, liquid composition, and puff behavior variables in combination, we illustrate how ECIG specifications can be realistically mandated to result in a target flux range.

Physical, behavioral, and cognitive effects of prenatal tobacco and postnatal secondhand smoke exposure

The purpose of this review is to examine the rapidly expanding literature regarding the effects of prenatal tobacco and postnatal secondhand smoke (SHS) exposure on child health and development. Mechanisms of SHS exposure are reviewed, including critical periods during which exposure to tobacco products appears to be particularly harmful to the developing fetus and child. The biological, biochemical, and neurologic effects of the small fraction of identified components of SHS are described. Research describing these adverse effects of both in utero and childhood exposure is reviewed, including findings from both animal models and humans. The following adverse physical outcomes are discussed: sudden infant death syndrome, low birth weight, decreased head circumference, respiratory infections, otitis media, asthma, childhood cancer, hearing loss, dental caries, and the metabolic syndrome. In addition, the association between the following adverse cognitive and behavioral outcomes and such exposures is described: conduct disorder, attention-deficit/hyperactivity disorder, poor academic achievement, and cognitive impairment. The evidence supporting the adverse effects of SHS exposure is extensive yet rapidly expanding due to improving technology and increased awareness of this profound public health problem. The growing use of alternative tobacco products, such as hookahs (a.k.a. waterpipes), and the scant literature on possible effects from prenatal and secondhand smoke exposure from these products are also discussed. A review of the current knowledge of this important subject has implications for future research as well as public policy and clinical practice.

Waterpipes and electronic cigarettes: increasing prevalence and expanding science

The prevalence of noncigarette tobacco product use is on the rise across the globe, especially for waterpipes (also known as hookah, narghile, and shisha) and electronic cigarettes (e-cigarettes). The scientific literature reveals that waterpipe tobacco smoking is associated with exposure to a variety of toxicants that can cause short- and long-term adverse health events. In contrast, there is far less evidence of health harms related to e-cigarette use, although the variety of products in this category makes it difficult to generalize. We searched the PubMed database for all publications on waterpipes and e-cigarettes from January 2000 to March 2014. The number of publications on waterpipes rose in a slow, linear pattern during this time, while the number of publications on e-cigarettes showed exponential growth. The different trends suggest there may be more interest in studying a novel nicotine product (the e-cigarette) over a traditional tobacco product (the waterpipe). We posit that, although the specific research needs for these products are different, public health would be served best by a more equitable research approach. Scientists should continue to devote attention to understanding the unknown long-term health effects of e-cigarettes and their potential to serve as harm reduction or smoking cessation tools while simultaneously investigating how to reduce waterpipe smoking given that it exposes users to toxicants known to cause harm to health. Recent regulatory action in the United States, which proposes to include waterpipes and e-cigarettes under some of the same regulations as tobacco cigarettes, makes such research particularly timely.

Carbon monoxide and respiratory symptoms in young adult passive smokers: a pilot study comparing waterpipe to cigarette

OBJECTIVES

Studies have correlated second hand smoke (SHS) with many diseases, especially respiratory effects. The goal of this study was to measure the impact of SHS on the respiratory symptoms and exhaled carbon monoxide.

MATERIAL AND METHODS

The study population consisted of 50 young workers in restaurants serving waterpipes, 48 university students who sit frequently in the university cafeteria where cigarette smoking is allowed and 49 university students spending time in places where smoking is not allowed. Subjects completed questionnaires on socio-demographic characteristics, respiratory symptoms and exposure to SHS. Exhaled carbon monoxide levels were measured. ANOVA and Chi-square tests were used when applicable as well as linear and logistic regression analysis.

RESULTS

Exposure to cigarette smoke in university (adjusted odds ratio (ORa) = 6.06) and occupational exposure to waterpipe smoke (ORa = 7.08) were predictors of chronic cough. Being married (ORa = 6.40), living near a heavy traffic road (ORa = 9.49) or near a local power generator (ORa = 7.54) appeared responsible for chronic sputum production. Moreover, predictors of chronic allergies were: being male (ORa = 7.81), living near a local power generator (ORa = 5.52) and having a family history of chronic respiratory diseases (ORa = 17.01). Carbon monoxide levels were augmented by the number of weekly hours of occupational exposure to waterpipe smoke (β = 1.46) and the number of daily hours of exposure to cigarette smoke (β = 1.14).

CONCLUSIONS

In summary, young non-smoker subjects demonstrated more chronic cough and elevated carbon monoxide levels when exposed to SHS while the effect of waterpipe was even more evident.

To what extent should waterpipe tobacco smoking become a public health priority?

BACKGROUND

Waterpipe tobacco smoking (WTS) popularity is increasing world-wide, and health effects are emerging in the light of evidence that WTS is perceived by users as less harmful than cigarette smoking. However, there remains a paucity of available evidence from which to draw firm conclusions about its public health significance.

AIMS

This narrative review aims to summarize WTS literature to date to inform tobacco control specialists and health-care professionals about this phenomenon and help them to assess whether or not WTS should become a public health priority.

METHODS

Standard electronic databases as well as conference proceedings and personal libraries were searched in English, French and Arabic with inclusive terminology for the variety of names given to WTS.

FINDINGS

Waterpipe smoke contains significant levels of toxins, some of which are known to be carcinogenic to humans. Recent epidemiological trends have established an increasing prevalence of WTS in the Middle East and the United States, particularly among adolescents. It is used commonly across multiple ethnicities and both genders with less of a social gradient than cigarette smoking. Attitudes and beliefs have been researched widely and several reasons for believing it is less harmful than cigarette smoking include water filtration and social acceptability. A wide range of diseases have been associated with WTS, but research in this area is relatively underdeveloped and a better evidence base is needed. Worryingly, the waterpipe industry, including waterpipe cafes, operates in an almost completely unregulated market and employs deceptive marketing techniques to attract new users.

CONCLUSIONS

Waterpipe tobacco smoking (WTS) appears to be on the increase, especially among younger users, and therefore represents a potential public health concern. While legislators should consider enforcing and extending existing tobacco laws to a growing WTS industry, further research is required to fill gaps in the literature and provide evidence-based interventions for tobacco control specialists and health-care professionals.

When water does not clear the smut from the smoke

Water-pipe (shisha) smoking is increasingly popular among young people in Europe and North America. The proponents claim that smoking water-pipe is much 'cleaner' than cigarettes. Although, a recent analysis of toxicant yields during 1-2 h water-pipe smoking resulted comparable to 100-200 cigarettes. We report a case of a 25-year-old patient with elevated haemoglobin, impaired concentration and reduced physical performance. Molecular investigations for JAK2 mutations and BCR-ABL fusion transcripts were negative and the arterial blood gas analysis revealed an elevated carboxyhaemoglobin of 6.1%. In a follow-up visit, the patient disclosed excessive shisha smoking. Secondary polycythaemia was diagnosed caused by chronic carbon monoxide poisoning. After cessation of shisha smoking all blood values returned to normal ranges within 6 weeks. Owing to the increasing popularity of water-pipe smoking and the anticipated health risks, our report should help to enhance awareness and advocate more information in tobacco prevention programmes on its potential toxicities.

AANA journal course: update for nurse anesthetists--Part3--Tobacco smoking using a waterpipe (hookah): what you need to know

Smoking tobacco using a waterpipe (hookah) is increasing worldwide and is remarkably common among adolescents and young adults in the United States. Contrary to misperceptions that waterpipe tobacco smoking presents fewer health risks than cigarette smoking, recent data demonstrate clearly that the smoke from a waterpipe contains many of the same toxicants that are in cigarettes, including the dependence-producing drug nicotine, cancer-causing polycyclic aromatic hydrocarbons, pulmonary disease-causing volatile aldehydes, and cardiovascular disease-causing carbon monoxide that can also lead to acute intoxication in waterpipe users. Because many anesthesia providers are likely treating waterpipe tobacco smokers, the goal of this AANA Journal Course is to describe a waterpipe, who uses a waterpipe to smoke tobacco, and the toxicants found in waterpipe smoke and waterpipe smokers. Based on available evidence, there is no indication that waterpipe tobacco smoking is any less risky to patient health than cigarette smoking. Anesthesia providers should begin to assess patients for this form of tobacco use explicitly and should consider addressing it as they do cigarette smoking, with the additional precaution of presurgery carboxyhemoglobin measurement.

The waterpipe: an emerging global risk for cancer

Tobacco smoking continues to be the leading preventable cause of morbidity and mortality worldwide. Each year more than 5 million smokers die prematurely because of their habit wreaking havoc on the welfare of families and communities worldwide. While cigarettes remain the main tobacco killer worldwide, for many youth tobacco use and addiction is maintained by means other than cigarettes. In particular, over the past decade, waterpipe smoking (a.k.a. hookah, shisha, narghile) has become increasingly popular among youth in the Middle East, and is rapidly spreading globally. Available evidence suggests that waterpipe smoking is associated with many of the known risks of tobacco smoking, particularly cancer. Despite these worrisome signs, policies and interventions to address this emerging public health problem have been lagging behind. In this short review I discuss briefly the evidence generated mostly in the past decade about the global spread of waterpipe smoking and its cancer risk potential.