Tamim et al. claim that “there has been no study that addresses [narghile smoking] trends on school students except for a study carried out among schoolchildren in Israel” [1]. We wish to inform them that in the same Lebanon, an excellent and deep study conducted by Zoughaib focussed on teenagers in schools of the Dahia of Beirut (southern part) of Beirut [2]. Would the Dahia not be anymore a part of this city ?

Then, making the same mistake as in a previous publication [3], Tamim et al. insist that tumbak is “a dark paste tobacco”. It is not, and the Middle East revival they describe is, as we said, in direct relation with the use of another product: tobamel (mu‘essel)(both words, in Arabic and Latin respectively, refer to honey), the flavoured tobacco [or no-tobacco]-molasses based mixture. It is absolutely not tumbak which is plain raw tobacco, smoked only by adults [4] and not by the young people surveyed in her study. This is a first source of confusion.

As for diseases related to narghile smoking, no study to date has established a link between the fact that narghile smoke would contain “higher levels of lead, chromium, and tar than cigarettes” and the existence of “respiratory illnesses like asthma in children and decreased fertility in adults” [1]. Besides, the levels of heavy metals and tar were obtained with a smoking machine set with parameters (and a particular type of charcoal) that are far from reflecting the reality of human narghile smoking [4]. Just to take “tar” as an example, no study so far has compared the qualitative differences –supposed, for many reasons, to be great- between cigarette and narghile tar. Regarding these health aspects, it is certainly not “highly probable that the primary/intermediate level-educated mothers are less aware of the health hazards associated with nargileh smoking”. Highly educated mothers also are not aware as well as fathers and everybody. Unfortunately, these hazards have never been soundly investigated because of a great confusion fuelled by repeated methodological bias in many studies [4].

Concerning methodology, Tamim et al. do not give any information on the main tool used for the survey. They only say that “the questionnaires included the same set of questions for both cigarette and narghile smoking”. Given the great differences in smoking patterns between cigarette and narghile use, this is an error that should have been avoided [4]. Indeed, many scholars agree today that a questionnaire for narghile smoking must be adapted, not only linguistically, but also from a tobaccological viewpoint.

Tamim et al. ask themselves: “Perhaps, deeper social meanings are attached to the nargileh in the form of expressing gender equality, sense of identity, means of power and liberty”. They support this statement with a source that would show, according to her, that “smoking nargileh was related to social liberation among women in Syria”. First, we wish to remind that these issues of sex “equality” (but also social and religious) were treated in depth in a socio-anthropological health-oriented transdisciplinary comprehensive research that began as early as 1996 [5]. Strangely enough, in their previous study on the same topic, Tamim et al. stated: “The gender difference in parental cigarette smoking rates in Lebanon (31.6% versus 16.6%) is not as pronounced. Maziak attributes the rate of female smoking in Syria to conservative social attitudes and a low level of social liberalization” [3]. These statements contradict each other. Although this discussion is irrelevant here because the new study deals with school students, we will only point out that this question of “social liberalization“ may reflect orientalist views even when the latter are put forward by “Orientals” themselves [3].

Finally, we found very strange the idea of launching “awareness campaigns at schools on the hazards of the misconceived harmless effects of nargileh smoking” or that of “illegalising nargileh smoking in public places” without mentioning at any moment a sole word about cigarettes. Indeed, are the latter considered less dangerous than narghile smoking, or perhaps, more “culturally accepted” ? Indeed, are not our kids, in Lebanon or in the USA, first of all, the victims of widely prevalent cigarette smoking ? Let us remember that the smoking prevalence in Lebanon reaches c. 60%. If the authors really wish to ban smoking, then let it be a ban on all forms of tobacco use, not only on the “Oriental” way of smoking. This is how the logics of science goes.

Dr Kamal T. Chaouachi Researcher and Consultant in Tobacco Control (Paris). http://PublicationsList.org/kamal.chaouachi Contact: kamchaAgmail.com

Competing interests: none.

REFERENCES [1] Tamim H, Al-Sahab B, Akkary G, Ghanem M, Tamim N, Roueiheb ZE, Kanj M, Afifi R. Cigarette and Nargileh Smoking Practices Among School Students in Beirut, Lebanon. Am J Health Behav 2007 (Jan-Feb);31(1):56-63.

[2] Zoughaib SS, Adib SM, Jabbour J. Prevalence and determinants of water pipe or narghile use among students in Beirut's southern suburbs. J Med Liban 2004 (Jul-Sep);52(3):142-8.

[3] Chaouachi K. E-Letter to the Editor: “Measuring Real Exposure to Narghile (Hookah, Shisha) Smoke and Other Concerns Related to Public Health”. European Journal of Public Health 2006 (Jul 2). A critical analysis of: Tamim H, Akkary G, El-Zein A, El-Roueiheb Z, El-Chemaly S. Exposure of pre-school children to passive cigarette and narghile smoke in Beirut. European Journal of Public Health 2006 (May 4): 4 pages. http://eurpub.oxfordjournals.org/cgi/eletters...

[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; 5:17. www.jnrbm.com/content/5/1/17

[5] Chaouachi K (book): Le narguilé. Anthropologie d’un mode d’usage de drogues douces. Paris : Ed. L'Harmattan ; 1997, 262 pages. [Eng.: An Anthropology of Narghile: its Use and Soft Drugs]