Hookah (Shisha, Narghile) Smoking and Environmental Tobacco Smoke (ETS). A critical review of the relevant literature and the public health consequences

Abstract

Hookah (narghile, shisha, "water-pipe") smoking is now seen by public health officials as a global tobacco epidemic. Cigarette Environmental Tobacco Smoke (ETS) is classically understood as a combination of Side-Stream Smoke (SSS) and Exhaled Main-Stream Smoke (EMSS), both diluted and aged. Some of the corresponding cigarette studies have served as the scientific basis for stringent legislation on indoor smoking across the world. Interestingly, one of the distinctive traits of the hookah device is that it generates almost no SSS. Indeed, its ETS is made up almost exclusively by the smoke exhaled by the smoker (EMSS), i.e. which has been filtered by the hookah at the level of the bowl, inside the water, along the hose and then by the smoker's respiratory tract itself. The present paper reviews the sparse and scattered scientific evidence available about hookah EMSS and the corresponding inferences that can be drawn from the composition of cigarette EMSS. The reviewed literature shows that most of hookah ETS is made up of EMSS and that the latter qualitatively differs from MSS. Keeping in mind that the first victim of passive smoking is the active smoker her/himself, the toxicity of hookah ETS for non-smokers should not be overestimated and hyped in an unscientific way.

Keywords: Hookah; environmental tobacco smoke (ETS); narghile; particles; public health; shisha; smoking; tobacco.

Figure 1.

The hookah (narghile, shisha) operating procedure and the diverse smoke flows (Chaouachi, Cours du DIU de Tabacologie, Universite Paris XI). English terms (from left to right): TOBAMEL (moassel: tobacco-molasses based mixture) inside the bowl [for “Tabac (tabamel)...”]; BODY CONTAINING A VERTICAL STEM [for “Cheminée avec logement...”]; VALVE [for “Soupape”]; WATER VESSEL [for “Vase” and “Eau”]; FLEXIBLE SUCTION HOSE [for “Tuyau d’aspiration souple”]; OUPUT [for “Sortie”]; ALUMINIUM FOIL (punched with holes) [for “Disque d’aluminium perforé”]; GLOWING COAL [for “Charbon de bois allumé”].

Figure 2.

Poster of the French INPES (Institut National pour la Prevention et l’Education a la Sante). This visual aid was used during the 2005 “World No Tobacco Day” campaign sponsored by the WHO. It shows a huge cloud of dense smoke (supposedly ETS) stemming from a hookah and featuring the spectrum of death.

Figure 3.

Cover of the American Lung Association’s report on “waterpipe”. It shows a small-size hookah generating SSS on its own (American Lung Association. An Emerging Deadly Trend: Waterpipe Tobacco Use. Feb 2007).

Figure 4.

Main-Stream Smoke and Side-Stream Smoke in a burning cigarette (Thielen et al. [26]).