We would like to elaborate on the important section dedicated to hookah (narghile) smoking in the study entitled “Tobacco and its trendy alternatives” (1). Under the “Argileh water pipe” heading, the authors state that “this device allows delivery of tobacco by inhaling through a mouthpiece after combustion and cooling of the steam in the apparatus.” To start with, the authors probably refer, of course, to the combustion of tobacco and not of the steam itself. We are afraid this “tobacco” -which is the one widely used in the world in general and the USA in particular (in hookah lounges, restaurants, by individuals at home and sold over the web as relevantly noticed) is actually not burnt. Indeed, there is no or few “combustion”. This is a crucial point.

Besides, this is not pure tobacco but a mixture involving, chiefly, between 30% and zero % of tobacco mixed with treacle (molasses) and other flavouring ingredients not to forget a moistener like glycerol. Such a mixture is simply heated. This fact has actually deep consequences on, among other, the quality of the tar which cannot be compared so easily to that generated by cigarette smoking (2).

The authors relevantly noticed that “many Middle Eastern restaurants complement their menus with a wide variety of hookah pipes and shisha tobacco to supplement the dining experience.” This observation is good and true. However, if this may sound new in the USA, this has actually been the case in the Middle East and other parts of Asia for ages.

>> “Manufacturers of the hookah apparatus and its accessories have made the tools widely available for users of all ages.”

Here, we wish to reassure the authors, and parents beyond, that the different sizes and shapes are not intended for children. Early and deep socio-anthropological research in Africa and Asia showed that this is a natural and old aspect (3). So, children in Africa and Asia are taught not to use the hookah until they reach the legal age (kind of “passage rite”)(2). Unfortunately, unsupported anecdotic claims in the other direction have created some confusion (4).

>>“One of the only articulated benefits to this tobacco alternative is the minimal release of sidestream smoke, which would ultimately place by-standers at risk for ETS exposure”

Smoke constituents in the case of the hookah are filtered out in three different ways and to varying degrees. Firstly, inside the water vessel; secondly during the long run of the smoke, from the bowl to the nozzle of the long hose, a distance of about two meters on average that may however reach, sometimes, four meters. Thirdly, during the production process of the smoke itself because the temperatures are extremely low in comparison with that at the burning tip of a cigarette as pointed out above. From a chemical point of view, this has great consequences. For instance, not only there is a “minimal release of sidestream smoke” but even the mainstream smoke is freed, to a great proportion, from famous irritants like acrolein, acetaldehyde, formaldehyde, and others (5). This is why the corresponding smoke is felt as “milder” than the harsh one produced by cigarette, even among non-smokers (6). Indeed, in our endeavour to develop a nationwide prevention plan for hookah use in France, we are taking this fact into consideration. This intelligent approach will allow us to gain credibility among smokers who may oppose our arguments.

Please note that we only mentioned irritants but a series of studies, including unpublished findings of ongoing research, suggests that even dangerous carcinogens might be filtered out (5). Undoubtedly, any exposure to tobacco smoke is not beneficial for health. However, if the authors meant a direct comparison with cigarette smoke, we think it is still premature to state that “this trendy smoking system places smokers at an increased risk to exposure to tobacco toxins.”

>>“Research on the mainstream aerosol components suggests that a single standard argileh smoking session may produce as much tar as 20 low-tar cigarettes.”

The authors are right to make this statement with caution because the model used in the study referred to was far from reflecting the reality of human smoking (6).

Finally, we also wish to invite the authors not to use the word “argileh” unless they explicitly refer to a few countries of the Middle East. Indeed, this word is actually Syro-Lebanese Arabic speak. By contrast, words like “shisha”, “hookah” or “narghile” have been used for centuries, are quickly identified by people (either in Asia and Africa or in the “West”), practical, short and, not the least of their qualities, to be found in English dictionaries (7).

We hope these few comments will shed some light on this complex issue and we are happy to see that the authors, uncommonly, use a great deal of caution when describing the state of the “epidemic” in their country.

Kamal Chaouachi (kamchaAgmail.com) Researcher and consultant in tobacco control (Paris)

___________ REFERENCES

(1) Deckers Sk, Farley J, Heath J. Tobacco and its trendy alternatives: implications for pediatric nurses. Crit Care Nurs Clin North Am. 2006 Mar;18(1):95-104.

(2) Chaouachi K (book): Tout savoir sur le narguilé. Société, culture, histoire et santé [Everything about Hookahs. Society, Culture, Origins and Health Aspects]. Paris, Maisonneuve et Larose 2007, 256 pages, colour. ISBN : 978-2-7068-1954-4

(3) Chaouachi K. Letter to the Editor: The Social Context of Individual and Collective Smoking: Similarities and Differences. Tobacco Control (1 April 2006). A critical analysis of the following study: Poland B, Frohlich K, Haines RJ, Mykhalovskiy E, Rock M, Sparks R. The social context of smoking: the next frontier in tobacco control?. Tobacco Control 2006;15:59-63. http://tc.bmjjournals.com/cgi/eletters/15/1/5...

(4) Chaouachi K. A Critique of the WHO's TobReg "Advisory Note" entitled: "Waterpipe Tobacco Smoking: Health Effects, Research Needs and Recommended Actions by Regulators”. Journal of Negative Results in Biomedicine 2006 (17 Nov); 5:17. http://www.jnrbm.com/content/5/1/17

(5) Chaouachi K. Narghile: aspetti chimici e farmacofisiologici [Biochemical and Pharmacologic Aspects of Narghile]. Tabaccologia. 2005; 3: 27-33. http://www.tabaccologia.org/archivio.htm

(6) Chaouachi K. The Medical Consequences of Narghile (Hookah, Shisha) Use in the World. Rev Epidemiol Sante Publique [Epidemiology and Public Health] 2007 (20 June):3. [Article in English][Epub Ahead of print (17 Apr)].

(7) Al-Belasy F. The Issue of Nomenclature: In Reply. Tobacco Control 2006 (18 June). http://tobaccocontrol.bmj.com/cgi/eletters/15...