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MAASSEL
• A new form of tobacco that came on the market in the 1990s
• In Syria, maassel is used exclusively by the vast majority of waterpipe users
Maziak, W. et al (2004).International Journal of Tuberculosis and Lung Disease, 8, 882–889
• Most maassel made for export is produced in Bahrain and Egypt
• Tobacco is fermented with molasses and fruit essence
• Maassel is moist and pliable, making it easier to use than other waterpipe tobaccos, and it has a pleasant taste and aroma
Kandela, P. (1997). Signs of trouble for hubble bubble. Lancet, 349, 9063
Kandela, P. (2000). Narghile smoking keeps Arabs in wonderland. Lancet, 356, 1175
OUTLINE • EPIDEMIOLOGICAL STUDIES
• SMOKING MACHINE STUDIES
• SMOKING TOPOGRAPHY
• MEASURE THE AMOUNTS OF CARCINOGENS
• ASSOCIATION WITH CANCER
• EFFECT ON ORAL HEALTH
• OTHER EFFECTS
• CARBON MONOXIDE POISONING & CARBOXYHEMOGLOBIN
CONCENTRATIONS
• COMPARATIVE ANALYSIS
• PULMONARY EFFECTS OF WATERPIPE SMOKING
• THE ACUTE EFFECTS OF WATER-PIPE SMOKING ON THE
CARDIORESPIRATORY SYSTEM
• PREGNANCY OUTCOMES
• TOBACCO DEPENDENCE IN WATERPIPE SMOKERS
• WHY DO WE NEED TO STUDY NARGHILE ? AND WHAT ?
• Tobacco Use Among Students Aged 13--15 Years --- Baghdad, Iraq, 2008 12.9%
• Cairo University medical students 17.6%. 2012
• College Athletes in the United States Pittsburgh, 2010 35.1%
• college students Michigan, 2012 . 71% of males and 52% of females reporting ever
smoking tobacco using a waterpipe and 22% of males and 5% of females reporting
current waterpipe smoking. Of the sample, 28% of males and 10% of females were
current cigarette smokers and 25% of males and 10% of females were current
marijuana users
• Arab American Adolescent 2006 27%; it increased from 23% at 14 years to 40% at 18
years
• Arab American students ; water pipe smoking than cigarettes (38% vs. 22%), and more
current (16% vs. 6%) and regular (7% vs. 3%) use of water pipes than cigarettes. 2009
• Pregnant women in Lebanon 2004 ,4% smoking only argileh, and 1.5% smoking both
cigarette and argileh
• 12.9% had ever smoked shisha Baghdad, Iraq, 2008
• Cairo University medical students current users of water pipe “ sheesha ” comprised
17.6%. 2012
• 8% of students at one British university were regular waterpipe smokers, 2009
• 416 students at the American University of Beirut 28.3% were current argileh smokers,
average initiation age was 16 years 2004
• 1,652 students, Al Hassa, Saudi Arabia WP (37.4%). 2012
• Worldwide ,an estimated 100 million daily users. 2004
• Practiced by approximately 1 billion people . 2003
• 170,430 UAE nationals aged ≥18 years shisha (waterpipe) (6.8%), 2010
Martinasek M et al .Curr Probl Pediatr Adolesc Health Care 2011;41:34-57
PREVALENCE AMONG YOUTH 2011
BREATHE study 2012
Middle East and North Africa
Khattab A et al .Respiratory Medicine (2012) 106(S2), S16–S24
A. Shihadeh . Food and Chemical Toxicology
41 (2003) 143–152
A standard smoking session was defined as
100 puffs, duration 3 s, with 30 s between
puffs (i.e. a cycle period of 33 s)
A smoking machine was designed and
smoke from an argileh fueled with charcoal
and loaded with 10 g of mo’assel tobacco
mixture was generated using puffing
parameters selected to approximate those of
argileh smokers.
The importance of the argileh water was
tested by including a condition where no
water was present in the bowl
Smoking Machine Apparatus
ma’assel
narghile smoke
condensates
Cigarette smokers typically take
8–12 puffs of 40–75 ml in about 5–
7 min and inhale 0.5–0.6 liters of
smoke
WPS sessions 20–80 min, 50–200
puffs , intake ranging from about
0.15 to 1 liter each session
The water pipe smoker may
therefore inhale the equivalent
of 100 or more cigarettes
2005
100-fold more tar, 4-fold more nicotine,
11-fold more CO, and 2- to 5-fold more
polycyclic aromatic hydrocarbons than did
a single cigarette
MAY
2013 Nakhla
Al-Waha
• 4 inpatient days & ad libitum • Water pipe for a minimum of twice per day
• CPD number and weight of cigarettes smoked or
weight of water pipe tobacco smoked, times,
duration, and number of sessions
Randomized, 2 arm, Crossover study
>
URINARY EXCRETION OF TOXIC SUBSTANCE BIOMARKERS
Smoke from water-pipes contains most of the compounds that
are also present in cigarette smoke, although in different
proportions
More importantly, the longer duration of a WPS session leads to
a much higher yield of toxic molecules than cigarette smoking
We believe that current water-pipe and tobacco smoking are
important risk factors in the initiation of cancer invasion and
metastasis through the epithelial – mesenchymal transition
(EMT) event and deregulation of its key genes
More molecular and cellular biological studies are necessary to
determine the exact role of tobacco and WPS in the progression
of several human carcinomas
2013
Oral squamous cell carcinoma (OSCC)
• Exposure to carcinogenic chemicals
• Mechanical trauma (irritation by the bamboo Plastic tubes used in the mouth piece)
• Heat generated from the smoke
• Chronic infection that would be associated with the use of one narghile by several individuals
N. S. Dar-Odeh and O. A. Abu-Hammad .BRITISH DENTAL JOURNAL 206 NO. 11 JUN 13 2009
El-Hakim I E et al
Int J Dermatol
1999; 38: 108–
110
A significant association was found with
Plaque and gingival indices
Bone loss among water pipe only smokers vs. non
smokers, OR rising to 7.5 (95% CI 3.0-18.3) among heavy
users
Pocket depth (>10 sites with a probing depth >5mm) OR of
5.1(95% CI 2.0-13.5) for WPS
2010
OTHER EFFECTS • Cardiovascular disease
Shafagoj & Mohammed, 2002
Jabbour, El-Roueiheb, & Sibai, 2003
Israel et al., 2003
Acute coronary syndrome Jassim Al Suwaidi et al . Postgrad Med J 2012;88:566–574
• Hematologic disturbances Sharma et al., 1997
Single water pipe smoking induces oxidation injury as evidenced by various markers Repeated daily smoking induces a persistent longer-lasting oxidation injury
Wolfram R et al . Life Sciences 74 (2003) 47–53
Hookah (narghile) smoking: A new emerging cause of secondary polycythemia SCHUSTER S et al . American Journal of Hematology 2011
• Genetic abnormalities Yadav & Thakur, 2000
El-Setouhy M, et al .Mutat Res 2008
Rammah M, Dandachi F, Salman R, Shihadeh A, El-Sabban M.. Toxicol Lett 2012;211(3):220–31
Alsatari ES, et al . Int J Occup Med Environ Health 2012;25(3):218–24
Waterpipe Smoking And The DRD2/ANKK1 Genotype Radwan GN et al. J Egypt Public Assoc 2010;85(3-4):131-48.
• Infectious diseases Potential to be linked to multiple communicable infectious diseases, including herpes simplex virus, Epstein-Barr
virus, and respiratory viruses, from sharing waterpipes and mouthpieces on the hose, a common practice of waterpipe smoking
Knishkowy & Amitai, 2005
Tuberculosis, due to the sharing of the waterpipe among smokers Salem et al. 1973
Israel et al.2003
World Health Organization [WHO], 2005
Munckhof W J, et al. Int J Tuberc Lung Dis 2003; 7: 860– 865
Meleigy M. Lancet Infect Dis 2007;7:448
Water pipe smoking is a lengthy process
Users receive a greater volume of smoke with every intake
More CO particles since coal is used to burn the tobacco
Generally takes place in closed environments
Smokers are also continuously exposed to emitted
particles
It takes an average of 1 h to smoke a water pipe
Exposure to CO is approximately seven times
greater compared with cigarettes
Karaca Y, et al. BMJ Case Rep 2013
COHb level 32.7%.
Comparison of Smoke Toxicants Yield
Standard Protocol for an average 1 h for Machine-
smoked Waterpipe and 5 min for a Cigarette
2013
Al Mutairi SS,. Respirology . 2006 ; 11 ( 4 ): 449 - 455
Kiter G . Respir Med . 2000 ; 94 ( 9 ): 891 – 894
Al-Fayez SF , Trop Geogr Med . 1988; 40( 2): 115- 123
Aydin A , . Ann Nucl Med . 2004 ; 18 ( 4 ): 285 - 289
Mohammad Y Int J Chron Obstruct Pulmon Dis . 2008 ; 3 ( 3 ): 405 - 414
Köseo ğlu N , Tuberk Toraks . 2006 ; 54 ( 3 ): 222 - 228
Comparison of FEV 1 /FVC in water-pipe smokers and nonsmokers
2011
Acute biologic
changes that
might result in
marked health
problems
2011
Several factors may explain this relatively
low level of interest in quitting waterpipe use
• Underappreciation of adverse health effects
• Perceive to be less harmful to health than cigarettes
(Kandela, 2000)
• Maassel, is aromatic and when passed through water delivers a cool, smooth smoke, making it is easy to see how such a perception could arise
• Social norms that support waterpipe use
• Perception that waterpipes are easy to quit and not addictive
2007
Jawad M , et al .British Journal of General Practice, February 2012
No legislation on the tobacco used in shisha beyond its prohibition indoors
Knishknowy B, Amitai Y. Pediatrics 2005; 116(1): 113–119
Many shisha tobacco companies do not even display the tobacco content contained within
Nakkash R, Khalil J. Tob Control 2010; 19(3): 235−239
Tobacco is not usually fully consumed
Shihadeh A . Food ChemToxicol 2003; 41(1): 143–152
TITRATION : shisha users are able to titrate up and down the tobacco based on smoking preference and
level of nicotine addiction
Salameh P et al . Nicotine Tob Res 2008; 10(1): 149–158
Documented evidence of shisha smokers experiencing cravings and withdrawal symptoms
MaziakW, et al .NicotineTob Res 2009; 11(7): 806–811 Shisha has been used both as a precursor to and a substitute for cigarettes
Hammal F, et al. Tob Control 2008; 17(2): e3
Jensen P, et al.Subst Use Misuse 2010; 45(7–8): 1245–1261
Re-evaluate and re-educate
Ask the ‘Shisha Question’
Attempt to quantify shisha use
Joining calls for more research
JOANNA KHALIL, RIMA AFIFI, FOUAD M. FOUAD, FADI HAMMAL, YARA JARALLAH, MOSTAFA
MOHAMED, RIMA NAKKASH
Understanding the social aspects of waterpipe tobacco
smoking is crucial to planning future interventions to
control waterpipe tobacco smoking among women and in
society at large
2013
THANK YOU
