. Author manuscript; available in PMC: 2020 May 7.

Published in final edited form as:Circulation. 2019 May 7;139(19):e917–e936. doi:10.1161/CIR.0000000000000671

Water Pipe (Hookah) Smoking and Cardiovascular DiseaseRisk

A Scientific Statement From the American Heart Association

Aruni Bhatnagar,Chair Wasim Maziak,Thomas Eissenberg,Kenneth D Ward,George Thurston,Brian A King,Erin L Sutfin,Caroline O Cobb,Merlyn Griffiths,Larry B Goldstein,Mary Rezk-Hanna,On behalf of the American Heart Association Behavioral Change forImproving Health Factors Committee of the Council on Lifestyle andCardiometabolic Health and Council on Epidemiology and Prevention; Council onCardiovascular and Stroke Nursing; Council on Quality of Care andOutcomesResearch; and Stroke Council

PMC Copyright notice

PMCID: PMC6600812 NIHMSID: NIHMS1033936 PMID:30845826

Abstract

Tobacco smoking with a water pipe or hookah is increasing globally. Thereare 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 offlavored tobacco, a social media environment that promotes water pipe smoking,and misperceptions about the addictive potential and potential adverse healtheffects of this form of tobacco use. There is growing evidence that water pipetobacco smoking affects heart rate, blood pressure regulation, baroreflexsensitivity, tissue oxygenation, and vascular function over the short term.Long-term water pipe use is associated with increased risk of coronary arterydisease. Several harmful or potentially harmful substances present in cigarettesmoke are also present in water pipe smoke, often at levels exceeding thosefound in cigarette smoke. Water pipe tobacco smokers have a higher risk ofinitiation of cigarette smoking than never smokers. Future studies that focus onthe long-term adverse health effects of intermittent water pipe tobacco use arecritical to strengthen the evidence base and to inform the regulation of waterpipe products and use. The objectives of this statement are to describe thedesign and operation of water pipes and their use patterns, to identify harmfuland potentially harmful constituents in water pipe smoke, to document thecardiovascular risks of water pipe use, to review current approaches to waterpipe smoking cessation, and to offer guidance to healthcare providers for theidentification and treatment of individuals who smoke tobacco using waterpipes.

Keywords: AHA Scientific Statements, cardiovascular disease, epidemiology, nicotine, particulate matter, smoking water pipes, tobacco, volatile organic compounds

Recent estimates suggest that between 0.85 and 1.1 billion people use tobaccoproducts world-wide.¹ These productsinclude cigarettes, cigars, cigarillos, pipes, water pipes, and smokeless tobacco. Theglobal use of electronic cigarettes (e-cigarettes) remains unknown, but among thetobacco products queried, manufactured cigarettes are favored by most smokers (82%). Theuse of tobacco is particularly high in middle-income countries such as China, India, andRussia. Nearly 300 million individuals in China and 275 million in India use tobaccoproducts daily.¹ In countries such asRussia and the Ukraine, 50% to 60% of adult men use some form of tobacco.¹ The use of tobacco products is also highin high-income countries such as the United States and the United Kingdom. Althoughthere have been significant declines in the rate of tobacco product use in somecountries, an increase in population has led the number of cigarette smokers worldwideto grow from 721 million in 1980 to 967 million in 2012.² Tobacco, therefore, is likely to remain a majorglobal public health threat for the foreseeable future.

Tobacco use remains a leading cause of disease and premature death. The WorldHealth Organization estimates that tobacco accounts for 9% of deathsworld-wide³ and that globallynearly 6 million people die of tobacco-related causes every year.⁴ To date, nearly 100 million deaths areattributable to tobacco use, and if current use patterns persist, tobacco use could kill>1 billion people in this century.⁴ Extensive literature documents the adverse health effects of tobaccouse, and although cigarette smoking increases the risk of many chronic illnesses,cardiovascular disease (CVD; inclusive of stroke) remains a leading cause of death insmokers.⁵ In the United States,as many as 30% of the all coronary heart disease deaths each year are related tocigarette smoking,⁶ and smoking doublesthe risk of premature cardiovascular mortality.⁷

As a result of the recognition of the high impact of tobacco use oncardiovascular health, tobacco control efforts are underway worldwide. In the UnitedStates, the American Heart Association (AHA) supports the implementation of provenpopulation-based tobacco control interventions, including antitobacco mass mediacampaigns and comprehensive smoke-free laws at the state and local levels. Proventobacco prevention and control measures, including comprehensive clean indoor air laws,increases in tobacco product prices, restriction of tobacco sales to those ≥21years of age, and US Food and Drug Administration regulation of tobacco products, arecritical population-based strategies endorsed by the AHA.⁸ The AHA identifies never having tried smoking andnever having smoked or having quit >12 months as 1 of the 7 components of idealcardiovascular health in Lifés Simple 7, selected on the basis of theircontributions to incident CVD.⁹

Although the AHA has published policy statements on smokeless tobacco¹⁰ and e-cigarettes,¹¹ to date, no AHA scientific statement hasaddressed the cardiovascular impact of water pipe tobacco smoking. Hence, the objectivesof this statement are to describe the design and operation of water pipes and thepatterns of use by adults and youths, to identify different harmful or potentiallyharmful constituents (HPHCs) of water pipe smoke, and to review potential cardiovasculareffects of water pipe use. The statement also offers a broad range of proven strategiesto reduce and prevent water pipe tobacco use and associated adverse cardiovasculareffects, discusses knowledge gaps that still need to be addressed, and provides concreteguidance to health-care providers for the identification and treatment of patients whosmoke water pipes.

DESIGN AND OPERATION

Water pipe that is used to smoke tobacco is known by many different terms,includinghookah, narghile, argileh, shisha, andgoza. This review uses the termwater pipe touniversally denote this product class. Over the years, the water pipe has had avariety of configurations, but as used today, it consists of a head or bowl (wheretobacco is placed), a body, a water base, and a hose that ends with a mouthpiece(Figure 1). Burning charcoalbriquettes/pieces are placed on top of the tobacco-filled bowl, which is usuallymade of clay, marble, or glass. The charcoal pieces are often separated from thetobacco by a perforated aluminum foil to allow the heated air to pass through thetobacco, and the holes in the bottom of the head allow the smoke to pass downthrough the stem, which can be of varying sizes and lengths. The down stem isimmersed in water to allow smoke to bubble through, which cools and humidifies thesmoke. Sometimes, mint leaves, fruits, or crushed ice are added to the water. Smokeemerging from the water passes through a hose, usually made of leather, vinyl, orplastic, which allows the smoke to be drawn by the user. Some water pipes have rigidmouth-piece reeds, whereas others may have multiple hose ports for simultaneous useby several smokers. The end of the hose is usually capped by a metal, wooden, orplastic mouth tip that can be covered by a disposable mouthpiece (to allow multipleusers and repeated use of the same water pipe hose).

Figure 1. — Adapted from Maziak et al.¹² Copyright © 2015, The Authors. This is an OpenAccess article distributed in accordance with the Creative Commons AttributionNon Commercial (CC-BY-NC 4.0) license, which permits others to distribute,remix, adapt, build upon this work non-commercially, and license theirderivative works on different terms, provided the original work is properlycited and the use is non-commercial.

Both the water pipe design and use patterns can affect smoke constituents andflavor. During a smoking session, the charcoal briquettes are adjusted andreplenished to maintain the desired taste, smoke concentration, and smoke volume.Either natural or quick-lighting charcoals, which are combusted, are used to heatthe tobacco. Although not systematically studied, the extent of nicotine generatedfrom tobacco is likely affected by the heating temperature, tobacco mixture used(including flavors, humectants, and additives), puffing topography, water pipe size,and amount of water in the water pipe bowl.^13,14 Water pipetobacco is usually a combination of dried fruit, tobacco, and humectants. Data frommany countries show thatmaassel is the currently preferred form oftobacco for water pipe smokers, especially among youth and young adults.^12,15–18Maassel (Arabic for honeyed) is a sweetened and flavored tobaccomixture. Before the introduction ofmaassel, most water pipesmokers globally used some form of raw tobacco that was crushed, mixed with water,squeezed, and molded before use.¹²Unlike the smooth aromatic smoke produced frommaassel, this methodusually produces a strong, harsh smoke.¹² In the United States, nearly 90% of youth use flavoredtobacco when smoking a water pipe.^16,19

Water pipes and their components (eg, charcoal, devices, and tobacco) andaccessories can be purchased from dedicated supply shops and increasingly frominternet vendors.¹⁹ Some vendorsclaim that the harmful effects of water pipe smoking are reduced by usingaccessories such as electronic heaters, mouthpiece Alters, water additives, and meshfittings to create smaller bubbles. However, the veracity of these claims remainsuncertain. Conventional water pipes are different from the electronic devices knownase-hookahs, e-shisha, orhookah pens, which areelectronic nicotine delivery systems that involve heating of a liquid (oftencontaining nicotine) that can be flavored to mimic the taste of flavored water pipetobacco. These electronic devices do not involve the use of water pipe tobaccoproducts/mixtures or charcoal combustion, 2 main features of conventional waterpipes.

Water pipe tobacco is sold in a wide variety of flavors, including apple,banana, berry, cherry, chocolate, coconut, coffee, cola, grape, kiwi, lemon,licorice, mango, mint, orange, peach, pineapple, rose, strawberry, tutti fruity,vanilla, and watermelon.²⁰ Thenames given to water pipe tobacco leverage the positive association that people havewith fruit, desserts, soft drinks, and candy. Flavored products are sold in colorfulpackaging that usually does not carry health warnings and are targeted to youngerconsumers.^21,22 The sweetened aroma of water pipe tobacco isnot as harsh as cigarette smoke, and water pipe tobacco is associated with lessthroat and upper respiratory tract irritation, thereby masking the harshness of thetobacco smoke and making it easier to start and continue smoking.^16,23

EPIDEMIOLOGY

Patterns of Water Pipe Smoking Among Youth

Prevalence of Use

The worldwide use of water pipes is extensive. In the 2016 NYTS(National Youth Tobacco Survey), a US nationally representative school-basedstudy, 4.8% (95% CI, 4.1–5.7%) of high school students (n=700 000)reported smoking tobacco using a water pipe over the prior 30 days, withsimilar rates among male (4.5%) and female (5.1%) students.²⁴ In the 2016 MTF survey(Monitoring the Future), 13.0% of 12th graders reported water pipe tobaccouse in the past year, with boys (15%) more likely to report water pipe usethan girls (11%).²⁵ Inwave 1 (2013–2014) data from the PATH study (Population Assessment ofTobacco and Health) of >13 000 youths 12 to 17 years ofage,²⁶ 7.5% (95%CI, 6.8–8.2) reported ever water pipe use, and 1.7% reported smokingwater pipe tobacco in the prior 30 days. Ever use and past-30-day use werehigher among 15- to 17-year-olds (13.0% and 2.9%, respectively) than 12- to14-year-olds (2.0% and 0.5%, respectively). Ever water pipe use was higheramong bisexual (19.3%) and gay/lesbian (17.7%) 14- to 17-year-olds thanthose identified as heterosexual (10.4%). Ever water pipe use was comparablebetween male (7.1%) and female (7.8%) participants but increased with eachyear of age.²⁶

Trends in Use

The NYTS found a nonlinear increase in past-30-day (current) waterpipe tobacco use among high school students (4.1% to 4.8%) between 2011 and2016²⁴; past-30-day use among high school students increasedbetween 2011 and 2014; and use peaked at 9.4% in 2014 before declining to4.8% in 2016. The MTF study found a steady increase in annual water pipe useamong 12th graders from 2010 (17.1%) to 2014 (22.9%), followed by a decreasein 2015 (19.8%) and 2016 (13.0%).²⁵ Reasons for this decline remain unclear.

International Use

The spread of water pipe use among younger populations is global.Data from the Global Youth Tobacco Survey, which included 13- to15-year-olds in 7 Middle Eastern countries, showed that the rates of waterpipe smoking ranged from 9% to 15%, which were higher than cigarette smokingrates in almost all countries studied.²⁷ Studies from some countries now show that waterpipe tobacco smoking is eclipsing cigarette smoking. For example, a study ofstudents in the United Kingdom during 2011 to 2012 found that current waterpipe use was more than twice as common as cigarette smoking (7.6% versus3.4%).²⁸

Characteristics of Water Pipe Smoking Among Youth

Flavored Use

Data from the 2014 NYTS revealed that 63.8% of high school studentswho reported water pipe use within the prior 30 days smoked flavoredtobacco. Data from wave 1 of the PATH study showed that among youth 12 to 17years of age, 89% of those who had ever used water pipe reported that theirfirst use involved a flavored product.²⁹

Frequency of Use

Most youth use water pipes intermittently. Data from PATH wave 1revealed that <1% (0.1%) of youth 12 to years of age use water pipedaily.²⁶

Polytobacco Use

The PATH wave 1 data showed that 43% of youth who used tobacco inthe past 30 days used >1 tobacco product. Of the 116 differentproduct combinations, the combination of e-cigarettes and water pipe was thethird most common one reported (5% of past-30-day tobacco users). Anadditional 4% of past-30-day tobacco users reported smoking cigarettes andwater pipe, and 3% used cigarettes, e-cigarettes, and water pipes.²⁶ Longitudinal studies inthe Middle East found that the risk of initiation of cigarette smoking washigher among water pipe smokers than among never smokers (adjusted hazardratio, 1.67 [95% CI, 1.46–1.92]) and that the risk increased with thefrequency of water pipe smoking.³⁰

Reasons for and Perceptions About Water Pipe Smoking Among Youth

Reasons for Use

Youths cite several reasons for water pipe use: entertainment,relaxation, boredom, curiosity, and somatic experiences, including thepleasant taste and smell, as well as tactile and visual elements,specifically the voluminous smoke.¹⁵ Culture is often cited as a reason for use amongthose from the Middle East, although for many years, use was largelyconfined to older men. However, use became more prominent among young peoplein the 1990s with the introduction and mass marketing of flavored water pipetobacco.³¹ Youthindicate that water pipe smoking allows them to meet others with a sharedcultural background.³²Data from wave 1 of PATH found that 12- to 17-year-olds reported using waterpipes use for several reasons, including the following: ˝I likesocializing while using them˝ (80%); ˝comes in flavors Ilike˝ (79%); ˝less harmful to me than cigarettes˝(61%); ˝affordability˝ (44%); and ˝people who areimportant to me use them˝ (36%).²⁹

Perceptions About Use

Water pipe use among youth is influenced by perceptions of itsaddictiveness and harm. Many youth believe that the chance of becomingaddicted to water pipe is low, perhaps because of their intermittent usepatterns.²⁹ Theyouth also perceive a lower risk of health harms associated with water pipesmoking compared with cigarette smoking. For example, youth water pipe usersand nonusers often believe that it is safer than smoking cigarettes becausethey think that the water ˝filters out toxins.˝^33,34 The wide variety of flavors of water pipe tobaccoand the cooling features of the water produce a mild smoke, which may leadto misperceptions of safety.¹⁶ Youth also cite the absence of health warnings andmedia campaigns describing harms as a reason that they perceive water pipesto be a safer tobacco product.¹⁶

Interest in Water Pipe Smoking

The increasing interest in water pipe smoking is evident from thevolume of related online searches. Between January 2004 and December 2013,water pipe online shopping searches increased by 291%, withhookah being the most common water pipe search term(190 000 average weekly searches), followed byshisha (127000 searches). Other relevant searches include Starbuzz, which is a commonbrand of water pipe tobacco and accessories. Comparing the relative searchvolume in 2013 for water pipe across the United States, United Kingdom,Australia, and Canada shows that the online interest in water pipe washighest in the United States (100% relative search volume, December 2013),followed by the United Kingdom (48.2% mean weekly relative search volume for2013), Canada (42.6%), and Australia (27.2%).³⁵

Growth in water pipe establishments or lounges as key places forsmoking continues, with many locations in areas of high population densityor near colleges and universities. In 2011, there were an estimated 725US-based water pipe establishments with at least 1 location in 43 states andthe District of Columbia.³⁴ By 2015, 1690 US water pipe establishments werereported, primarily in large metropolitan areas (ie, Los Angeles, New York,Chicago, Atlanta, and Miami). Most of these establishments were within 3 to9 miles of college or university campuses with a student population of≥20 000.³⁶ Theseestablishments or lounges could also influence youth interest in and use ofthese products. Nearly 30% of high school students in San Diego learnedabout water pipe smoking by seeing a water pipe lounge, and current waterpipe users were more likely to know of a water pipe lounge in theircommunity.³⁷Furthermore, lounges have reinforced pro-water pipe messages inadvertisements and on social networking sites.³⁸

Influence of Social Media

Pro–water pipe messages on social media, which are widespreadand unregulated, are likely to add to the proliferation of water pipe use. Astudy of the profiles of 307 Facebook users, recruited from among studentsat 2 US universities, found that 27.8% of participants had ever smoked waterpipe and 5.3% of the profiles contained water pipe references.³⁶ Water pipe users reportedsmoking tobacco (78%), hash (12%), or both tobacco and marijuana/hash (10%)in their apparatus. There were no significant differences in water pipe usebased on age, sex, or race.³⁹ Nearly a quarter of the pro-water pipe tweets onTwitter are commercial promotions of water pipe at bars, clubs, events, andother venues, encouraging the social aspects of water pipe that appeal toyoung people.⁴⁰ In 2014,>12 000 water pipe–related tweets were sent daily, mostly fromTwitter users with high influence and many who are pro water pipe.Eighty-seven percent of these tweets normalized water pipe or promoted itsuse, whereas 7% were against water pipe or discouraged its use.⁴¹ Positive tweets fromindividuals tend to emphasize the enjoyable experience of water pipesmoking, and tweets from business entities often highlight the potential tohave a positive water pipe smoking experience.⁴²

A vast majority of the water pipe pins on Pinterest areimage-based⁴⁰ andmore often portray water pipe smoking in a more positive than negativelight, which tends to trigger more repins, likes, and higher levels ofengagement.⁴³ OnYouTube, water pipe–related videos are more likely thancigarette-related videos to portray tobacco use positively, to describesmoking water pipe tricks, and to provide practical information on how tosmoke water pipe. Some videos frame water pipe preparation as an art form orhobby, requiring patience and experience to cultivate and perfect.⁴⁴

Enticement to engage in water pipe use by water pipe establishmentshas been depicted on photo-based and microblog websites. For example, arecent study of water pipe promotion and use on Instagram foundcross-promotion of water pipe and alcohol use by water pipe establishments,suggesting that these venues regularly depict and promote polysubstanceuse.⁴⁵ On Tumblr,the most prominent features portrayed by those who post include referencesto or images of water pipes, sexuality, socializing, alcohol, water pipesmoke, and tricks performed with the water pipe smoke.⁴⁶

Patterns of Water Pipe Smoking Among Adults

Prevalence of Use

Water pipe use varies across population subgroups. During 2013 to2014, the proportion of US adults (age >18 years) who reported usinga water pipe in the NATS (National Adult Tobacco Survey) everyday, somedays, or rarely was 4.3%, which translates to ≈10 millionadults.⁴⁷ Theproportion who reported at least some frequency of water pipe use variedwith sociodemographic groups, most notably with age. Prevalence was highestamong those 18 to 24 years of age (13.6%) compared with those 25 to 44(9.0%), 45 to 64 (4.7%), or ≥65 (1.5%) years of age. Young adults, 18to 24 years of age, accounted for 55.8% of water pipe smokersnationwide.⁴⁷

Trends in Use

Although water pipe use has generally increased over time, thispattern has varied with age. In the United States, data on trends in adultwater pipe tobacco use are limited given that questions about these productswere first added to national surveys beginning in 2009 to 2010 and thatdifferent definitions, methods, and samples were used in differentpopulations over time. Findings from the NATS indicate that past-30-day(current) water pipe use among US adults has generally increased from 1.5%during 2009 to 2010 to 3.2% in 2013 to 2014.^47,48 This increase was driven largely by young adults, withprevalence among those 18 to 24 years of age increasing from 7.8% in 2009 to2010 to 15.8% in 2013 to 2014.^47,48

International Use

Outside the United States, data on prevalence and trends of waterpipe use indicate markedly increasing interest in these products, includingamong adults. The worldwide prevalence of hookah use^12,49–53 isshown inFigure 2. The rates of currentuse, however, are generally lower among adults compared with youngpeople.¹²Moreover, use varies considerably across countries and regions.^12,54 Among individuals ≥15 years of age from 44countries who participated in the Global Adult Tobacco Survey or the SpecialEurobarometer 385 during 2008 to 2012, there was virtually no water pipesmoking in assessed countries from the Americas, Southeast Asia, andAfrica.⁵⁴ Withinthe Eastern Mediterranean region, prevalence of current water pipe use was3.3% in Egypt.⁵⁴ In theWestern Pacific region, prevalence ranged from virtually no use in China,the Philippines, and Malaysia to 6.4% in Vietnam.⁵⁴ Some of the countries with thehighest prevalence of adult water pipe smoking are located in Europe;current use was highest in Denmark (8.4%), Cyprus (8.5%), Lithuania (9.0%),and Latvia (11.5%).⁵⁴Across many countries and regions, current use of water pipes is generallyhigher / among men than among women.⁵⁴

Characteristics of Water Pipe Smoking Among Adults

Flavored Use

Flavored tobacco is commonly used by water pipe smokers. During 2013to 2014, an estimated 82.3% of US adults assessed via the NATS who usedwater pipe in the prior 30 days reported using a flavored product.⁵⁵ Among users, the mostprevalent flavor used was fruit (74.0%), followed by menthol/mint (18.9%),candy/chocolate/other sweet (17.4%), clove/spice/herb (4.3%), alcohol(3.2%), and other (3.0%).⁵⁵ Among those who used water pipe in the past 30 days,flavored use was similar among men (81.3%) and women (83.6%) and generallydecreased with age. Among 18- to 24-year-olds who used a water pipe in thepast 30 days, flavored product use was 85.9% compared with 66.8% among 45-to 64-year-olds.⁵⁵Flavored use did not vary by race/ethnicity.⁵⁵ Flavored use ranged from 81.1% amongthose with annual household income of >$100 000 to 85.4% among thosewith annual household income of <$20 000.⁵⁵ Among past-30- day users, theprevalence of flavored use ranged from 75.2% among those with abachelor’s degree or higher to 83.9% among those with less than ahigh school diploma.⁵⁵Flavored use was 89.6% among lesbian, gay, or bisexual adults compared with81.2% among heterosexual adults.⁵⁵ By US region, flavored use was 77.7% in the West,82.1% in the South, 86.1% in the Midwest, and 86.3% in theNortheast.⁵⁵During 2013 to 2014, the prevalence of flavored water pipe use was 83.8%among current cigarette smokers, 82.2% among recent former cigarettesmokers, 81.2% among long-term former cigarette smokers, and 81.4% amongnever cigarette smokers.⁵⁵

Frequency of Use

Many water pipe users also partake of other tobacco products. During2013 to 2014, the proportion of US adults assessed via the NATS who reportedusing a water pipe every day or some days was 0.6% (1.4 million adults);with the inclusion of adults who reported that they rarely use a water pipe,the proportion increased to 4.3% (10.0 million adults).⁴⁷ Among adults who smoked during theprior 30 days, the use of flavored water pipe was more common amongsome-days users (91.7%) compared with rare users (80.8%).⁵⁵

Polytobacco Use

Among US adults who reported using tobacco during 2013 to 2014assessed via the PATH survey, 62.2% used 1, 22.5% used 2, and 15.3% used≥3 types of tobacco products.²⁶ Among the 331 reported combinations of polytobaccouse among US adult tobacco users, the combination of cigarettes ande-cigarettes was the most common (23%), followed by the use of cigarettesand water pipes (6%).²⁶ Inaddition, 3% of US adult tobacco users reported current cigarette,e-cigarette, and water pipe use; 2% reported current e-cigarette and waterpipe use; 2% reported current cigarillo and water pipe use; and 1% reportedtraditional cigar and water pipe use.²⁶ Current water pipe tobacco smoking is associatedwith increased risk of cigarette smoking among young adults; among those whohad never smoked cigarettes, those who smoked water pipe at least rarelywere 2.3 times more likely to begin cigarette smoking compared with thosewho were not current water pipe smokers.⁵⁶

Reasons for and Perceptions About Water Pipe Smoking Among Adults

Reasons for Use

Multiple reasons have been cited for water pipe tobacco smoking,including social and cultural acceptability. More specifically, some adult waterpipe smokers, particularly those from the Middle East or of Middle Easterndescent, report that water pipe use is rooted in their cultural traditions andoccurs during family and other social gatherings.⁵⁷ Additional factors influencing waterpipe use include ease of access through family, friends, and storefronts such ascafés and bars.⁵⁷ Inaddition, promotion of water pipes through traditional advertising, theinternet, and social networks is a driver for water pipe initiation and use,particularly among younger adults.⁵⁷ Finally, some studies suggest that smoking water pipe mayhave self-perceived positive psychological effects on users, including improvedconcentration and self-efficiency, as well as reductions in stress, anger, anddepression,⁵⁷ perhapsin part as a result of nicotine exposure, which can increase attention andscores in vigilance tasks.⁵⁸

Perceptions About Use

The use of water pipes among adults may be influenced bymisperceptions about its addictiveness and health risks, particularly amongyounger adults.⁵⁷ Forexample, some users perceive that the probability of addiction is low if theproduct is used occasionally, and most users believe that they can easilyquit water pipe smoking.⁵⁷There is evidence, however, that adolescent water pipe users beginexhibiting signs of dependence relatively quickly (<1 year aftertheir first use) and when smoking only occasionally (7.5 water pipes permonth or 6 d/mo, on average).⁵⁹ The initiation and use of water pipes might also beinfluenced by perceptions of the risk of smoking water pipes compared withcigarettes.For example, 1 study found that the majority of water pipe users(58.3%) perceived water pipe smoking to be less harmful than cigarettesmoking, with more frequent users being more likely to have thisperception.⁶⁰ Thisperception could be based on the belief that these products contain lessnicotine and harmful chemicals than cigarettes because the smoke passesthrough water.⁵⁷ Otherstudies, however, indicate that some users consider the risk of smokingwater pipe to be equal to or more than that of smoking cigarettes⁵⁷ and that individuals whoreceive educational information about the harms of water pipe smoking reportgreater perceived risk about the use of these products.⁶¹

WATER PIPE SMOKE CONSTITUENTS

The range of HPHCs found in water pipe tobacco smoke is similar to that ofthe chemicals found in the smoke of combustible cigarettes.⁵³ There are, however, important differences.The HPHC profiles of water pipes differ from those of cigarettes because of the useof charcoal to heat the tobacco, the temperature at which the tobacco is heated orburned, and the volume of delivered smoke.⁵³ Moreover, the patterns of water pipe use and cigarettesmoking differ, resulting in differing exposures. In water pipes, tobacco is heatedto ≈450°C with typical quick-lighting charcoal, which is lower thanthe temperature in cigarettes (≈900°C).¹³ Thus, the temperature attained in waterpipes is usually below that required for pyrolysis or outright combustion.Nevertheless, under standard smoking machine protocols based on Middle Easternsmoking patterns (which may be different from those in the United States),¹³ a single water pipe smokingsession generates on average 70 times higher levels of tar, 2.5 times greater levelsof phenanthrene, and 11-fold higher levels of carbon monoxide (CO) than cigarettes.Even when normalized per 1 mg of nicotine in the tobacco, the CO yield is≈3-fold higher from water pipe than from a standard cigarette.¹⁴ It is likely, however, that thetrue level of HPHC exposure differs from the levels generated by smoking machinesbecause of differences in use patterns.

Water pipe smoking is a social activity, and typical users are likely to beexposed to secondhand smoke from the product itself (ie, sidestream smoke), as wellas secondhand smoke exhaled by users (ie, mainstream smoke). The complex patterns ofexposure during typical water pipe smoking sessions remain unclear, butbiomarker-based estimates provide a reasonable assessment of HPHC exposure in waterpipe users. The main HPHCs of cardiovascular concern in water pipe users includenicotine, particulate matter (PM), CO, volatile organic chemicals, polycyclicaromatic hydrocarbons (PAHs), acrolein, heavy metals, and arsenic. The comparativelevels of different HPHCs in water pipe emissions versus combustiblecigarettes^13,62,63are shown inFigure 3.

Figure 3. — Data are presented as fold difference between a typical session of waterpipe use and a single cigarette.^13,62,63

Nicotine

Like cigarette smoke, water pipe smoke is high in nicotine. Ameta-analysis of water pipe users from 4 countries indicates that, on average,daily use of water pipe tobacco produced a 24-hour urinary cotinine level of0.783 mg/mL, which is equivalent to smoking 10 cigarettes per day. Even a singlesession of water pipe use over a 4-day period delivered the nicotine equivalentof smoking 2 cigarettes over a 1-day period.⁶⁴ During a typical isolated water pipe use session in aclinical research unit, water pipe tobacco smokers had a systemic dose of 2.5 mgof nicotine, which is equivalent to the dose of smoking 2 to 3cigarettes.⁶⁵ In anaturalistic study of water pipe tobacco smokers in water pipe bars or lounges,a 73-fold increase in urine nicotine concentration was reported in water pipesmokers after a single typical session.⁵⁷ The average plasma nicotine concentration over thefirst 24 hours after smoking a full bowl of water pipe tobacco was equivalent tothat after smoking 2 to 3 cigarettes.⁶⁶

Particulate Matter

Water pipe tobacco smoking generates high levels of PM. The size of theparticles generated in mainstream smoke ranges from 0.01 to 0.2 μm, witha median diameter of 0.04 to 0.05 μm,^62,67 although theparticle size can be as large as 0.15 μm.⁶⁸ In comparison, cigarette smoke generatesparticles between 0.15 and 0.5 μm, with a median particle size of 0.1pm.^62,67 The breathing volume of water pipe smoke(1 L in this study) was found to contain a greater number of particles(70×10⁹) than 1 breath (45 mL) of a cigarette(9.2×10⁹ particles).⁶² Given that a typical 1-hour session of water pipeconsists of «100 puffs compared with ≈11 puffs of a cigarette, asingle session of water pipe use is likely to lead to at least a 10-fold greaterexposure to tobacco PM. Even after 5 minutes, the number of particles drawn froma water pipe is twice that generated by a cigarette in a smokingmachine.⁶⁷

Carbon Monoxide

Water pipes are also a significant source of CO exposure. Instandardized smoking machine protocols, a single water pipe tobacco use sessiongenerates 35 times more CO than a cigarette.⁶⁷ In addition, side-stream emission of CO during a singlesession is estimated to be equivalent to the amount of CO emitted by 10cigarette smokers in the same space.⁶⁷ Most of the CO emitted by water pipes seems to be fromcharcoal because replacing charcoal with an electric heater decreases COemissions by 90%.⁶⁹ Exposureestimates from water pipe users show that a single 30- to 90-minute water pipesmoking session exposes smokers to high levels of CO with exhaled levels between12 and 60 ppm.^65,70–72 The levels of CO in water pipe bar patrons (mean, 30.8ppm) were much higher than in patrons of traditional bars where cigarettesmoking was permitted (mean, 8.9 ppm).⁷¹ The exhaled CO of water pipe smokers after 1 session(43 ppm) was found to be greater than the amount reported for 1-pack-per-daycigarette smokers (17 ppm).⁷²In a laboratory study, CO increased by 24 ppm after 45 minutes of water pipesmoking and 3 ppm after smoking a single cigarette (a nearly 8-fold greaterabundance in water pipe than cigarette smoke).⁷⁰ Relative to a single cigarette, a singlesession of water pipe use is associated with 3-times-greater bloodcarboxyhemoglobin levels, even when peak plasma nicotine levels arecomparable.⁷⁰ The meanlevels of CO (mean, 6.7 ppm) and PM <2.5 μm (PM_2.5;mean, 264 μg/m³) in water pipe establishments were higher thanthe levels of CO (0.4 ppm) and PM_2.5 (215 μg/m³) ina casino where smoking was permitted.⁷³ Exposure to high levels of CO in water pipe smoke couldlead to acute poisoning,⁷⁴which includes side effects such as syncope, headache, nausea, or seizure. Thesesymptoms usually appear when the carboxyhemoglobin levels equal or exceed17%.⁷⁵ Several casesof CO poisoning related to water pipe smoking in young, otherwise healthy adultshave been reported in the literature.^75–78

Volatile Organic Compounds

The mainstream tobacco smoke of water pipes contains many of the samevolatile organic chemicals present in cigarette smoke that have been associatedwith adverse cardiovascular effects. These include acrolein, benzene, phenols,and propioaldehyde.^72–75 Compared with 1 reference 1R4Fcigarette smoke session, a single water pipe tobacco smoke session (generatedwith a standardized smoking machine protocol) produced 27-fold greater levels offormaldehyde, 4-fold greater acetaldehyde, 19-fold greater acrolein, 9-foldgreater propional-dehyde, and 4-fold greater methacrolein levels.⁷⁹ Water pipe mainstream tobaccosmoke also contains 6-fold higher benzene (micrograms per session) thancigarette smoke (micrograms per cigarette).⁶³ The levels of carbonyls in water pipe emissions couldbe decreased by increasing the amount of humectants in the unburned tobacco,which lowers the temperature in the water pipe head.⁸⁰ Estimates of exposure to typical users,assessed by measuring the urinary volatile organic chemical metabolites, suggestthat water pipe smokers are exposed to much higher levels of benzene thancigarette smokers.⁸¹ In ashort-term exposure study, the urinary levels of the acrolein metabolite3-hydroxypropyl mercapturic acid increased 1.4 times after water pipesmoking.⁸² Similarly,urinary levels of S-phenylmercapturic acid, a metabolite of benzene, wereincreased 4.2 times after water pipe social events,⁸³ suggesting that water pipe smoking maybe a significant source of both benzene and acrolein exposure.

Polycyclic Aromatic Hydrocarbons

A range of PAHs has been identified in water pipe mainstream tobaccosmoke under standardized machine smoking protocols.^14,67,84 The profileof PAH emissions by water pipes differs from that of cigarettes. Although theconcentration of PAH per 1 mL smoke is lower than in cigarettes, a typical waterpipe smoking session, because of its length, delivers 20 times the total PAHyields and 50 times the heavy (4- to 5-ring) PAHs. The levels of some PAHs inwater pipe emissions may be 2 to 3 orders of magnitude higher than in cigaretteemissions. Overall, a typical water pipe smoking session can potentially resultin PAH exposure equivalent to 50 cigarettes, in part because of thesignificantly larger amount of smoke volume generated during 1 water pipesession.⁸⁴ As with CO,most (50%⁸⁵ or75%–92%⁶⁹) PAHsemitted in mainstream (exhaled from the user) and sidestream (emitted from theburning tobacco) water pipe smoke may be derived from charcoal rather thantobacco and therefore not affected by the presence of nicotine.⁸⁶ Estimates of exposure to PAHsby measuring urinary metabolites indicate that water pipe users take in more ofthe higher-molecular-weight PAHs such as phenanthrene. In comparison, the intakeof low-molecular-weight PAHs, naphthalene and fluorine is higher duringcigarette smoking.⁸¹

Heavy Metals and Arsenic

Multiple heavy metals (Be, Ni, Co, Cr, and Pb) have been detected inwater pipe tobacco smoke.¹³As¹³ and Zn⁶⁸ have also been detected insome samples of water pipe smoke. Although the concentrations of As, Be, and Niare similar or lower in water pipe condensates, the concentrations of Co, Cr,and Pb are higher than in commercial cigarettes. The source of the metals is notclear but may derive from a combination of emissions from tobacco and charcoal.Different types of raw synthetic and natural charcoals contain heavy metals suchas Zn, Fe, Cd, Vd, Al, Pb, Cr, Mn, and Co, which are at concentrations similarto or higher than the concentration in cigarette smoke.⁸⁷

CARDIOVASCULAR EFFECTS OF WATER PIPE SMOKING

Because both mainstream and sidestream water pipe tobacco smoke containsconstituents similar to those generated by cigarettes, the use of water pipes couldsimilarly lead to short-term cardiovascular changes in addition to long-termcardiovascular effects. These short-and long-term effects could increase CVD riskand precipitate cardiovascular events. Although the cardiovascular health effectsand the underlying mechanisms by which water pipe tobacco smoking increases CVD riskhave not been studied to the same extent as those of cigarettes, there are likelysimilar. Overlapping mechanisms underlying the effects of both tobacco productsinclude sympathetic activation, vascular dysfunction, systemic inflammation andoxidative stress, insulin resistance, enhanced coagulation and thrombosis, and lipidperoxidation (Figure 4). Additionalconstituents specific to water pipe tobacco smoking that are emitted from theburning charcoal, such as the high levels of CO and benzene, must be considered whendata are extrapolated from cigarette smoking.

Figure 4. — CO indicates carbon monoxide; PM, particulate matter; and VOC, volatileorganic chemical

Cardiovascular Effects of Short-Term Water Pipe Smoking

As with cigarette smoking, water pipe tobacco smoking leads to animmediate and transient increase in heart rate and systolic blood pressure. Theextent of these changes varies across studies because of the difference inexposure conditions, participant demographics, and use patterns. In general, inyoung, healthy individuals, smoking tobacco via a water pipe for 15 to 30minutes increases heart rate by 6 to 13 beats per minute, systolic bloodpressure by 3 to 16 mm Hg,^88–91 anddiastolic blood pressure by 2 to 14 mm Hg.^88,89,91 These changes are accompanied by adecrease in heart rate variability^91–93 and amodest increase in coronary blood flow.⁹³ Water pipe tobacco smoking increases myocardial oxygendemand similar to the effects of cigarette smoking.⁹³ Overall, the short-term cardiovasculareffects are consistent with the sympathomimetic effects of nicotine, which aremediated by β-adrenergic activation. Indeed, in a double-blindplacebo-controlled study, no changes in heart rate were observed when aflavor-matched, tobacco-free preparation was smoked.⁹⁴ Like-wise, the decrease in heart ratevariability with water pipe smoking was prevented by β-adrenergicblockade.⁹³ Therefore,the short-term hemodynamic effects of water pipe tobacco smoking may beattributed to nicotine-induced β-adrenergic stimulation.

In addition to changes in cardiac function and blood flow, water pipetobacco smoking has been found to affect vascular function in some,^95,96 but not all studies.⁹⁷ Measurements of vascular function withplethysmography found that water pipe smoking for 30 minutes immediatelyincreases vascular resistance and decreases forearm blood flow, venous outflow,and venous capacitance.⁹⁶ Bothcentral and peripheral components are affected immediately aftersmoking.⁹⁵ Theseeffects are similar to those associated with cigarette smoking and have beenrelated to attenuated endothelium-dependent vasodilation and hyperactiveneurohormonal response to nicotine exposure or potentially other oxidants inwater pipe smoke, increasing oxidative stress.⁹⁶ Indeed, although water pipe tobaccosmoking immediately increases the plasma concentration of 8-epi-prostaglandinF2α (a biomarker for oxidative injury),⁹⁸ it decreases proinflammatory cytokines,including interleukin-4, interleukin-5, interleukin-17, andγ-interferon.⁹⁷

The short-term hemodynamic effects of water pipe tobacco smoking mayalso be related to changes in exercise capacity. The vascular responses to waterpipe smoking are exacerbated among individuals with lower levels of physicalactivity or physical fitness.⁹⁶ In a pilot study of healthy participants, water pipetobacco smoking was associated with an impairment of lung function and exercisecapacity. During exercise, after water pipe tobacco smoking, a decrease inoxygen pulse (from 10.89 to 9.97 mL oxygen per beat) was found, which was alsoassociated with an increase in the heart rate–oxygen consumptionrelationship.⁹⁰ Thesechanges may be related to the increase in blood CO levels, which may, in turn,result in a decrease in the oxygen-carrying capacity of the blood.⁹⁰

Cardiovascular Effects of Long-Term Water Pipe Smoking

Several studies have reported an association of long-term water pipe usewith increased CVD risk, severity, and mortality.^92–94 Most such studies are from the Middle East andSoutheast Asia, where water pipe use is most prevalent. However, theapplicability of these findings to other geographic areas where populationdemographics and use patterns differ is uncertain. Moreover, most of thesestudies have a small sample size, incomplete exposure assessment, and a lack ofclinical verification of events. Nevertheless, taken together, these dataprovide an overall indication of a potential for cardiovascular effects fromlong-term water pipe smoking.

In a small cohort of participants with established CVD (documented bycoronary angiography), water pipe smoking has been associated with higher bloodpressure and heart rate. Elevated blood pressure was more pronounced with dualuse (cigarette and water pipe), although exclusive water pipe use was associatedwith higher blood pressure than nonsmoking.⁹⁹ In a population-based study from Syria, daily waterpipe smokers compared with never smokers were found on average to be 2.26kg/m² (95% CI, 0.79–3.72; ≈12 lb) heavier, evenafter adjustment for cigarette smoking, number of chronic diseases, age, sex,income, and marital status. They also had nearly 3-fold higher odds of beingobese (odds ratio [OR], 2.87).¹⁰⁰ In a study from the Punjab province of Pakistan, long-termwater pipe use was associated with hypertension (OR, 1.95), hyperlipidemia (OR,1.63), hyperglycemia (OR, 1.82), and abdominal obesity (OR, 1.93) but not withcirculating levels of high-density lipoprotein.¹⁰¹ Age-adjusted prevalence of metabolicsyndrome (identified in accordance with the International Diabetes Federationdefinition) was higher among current water pipe smokers thannonsmokers.¹⁰¹ Takentogether, these findings suggest that the cardiovascular risk profile associatedwith long-term water pipe use is similar, but not identical, to that ofcigarette smoking.

A direct comparison of vascular function in cigarette and water pipetobacco smokers shows that long-term water pipe users have more severedecrements in endothelium-dependent, flow-mediated dilation than cigarettesmokers. This difference may be related to the extent of exposure.¹⁰² Most water pipe users in thestudy smoked 3 to 5 sessions per day, whereas most cigarette smokers smoked 10to 20 cigarettes per day. Because differences in the frequency of use betweenboth products could result in higher exposure to HPHCs and nicotine in waterpipe smokers, it seems likely that more severe depression of vascular functionin water pipe smokers may be related to a higher level of exposure, particularlybecause there was an inverse correlation between flow-mediated dilation andsmoking duration.¹⁰² Althoughthe mechanisms by which long-term water pipe smoking leads to endothelialdysfunction remain to be determined, it is speculated that these may be theresult of an underlying chronic inflammatory state. Indeed, there is adose-dependent relationship between plasma fibrinogen levels and cigarette andwater pipe smoking. In otherwise healthy men 20 to 75 years of age, the plasmalevels of fibrinogen were elevated markedly in long-term water pipe users(especially those who smoked for >10 years) compared withnonsmokers,¹⁰³indicating again that CVD risk burden associated with water pipe smoking may behigher than that associated with cigarette smoking.

There are only limited data to assess the impact of water pipe usedirectly on the severity of CVD and associated mortality rates. Nevertheless,lifetime exposures exceeding 40 water pipe-years (2 water pipes per day for atotal of 20 years or 1 water pipe for 40 years) are associated with a 3-foldincrease in the odds of angio-graphically diagnosed coronary arterystenosis.¹⁰⁴ Coronarydisease, estimated as the mean Duke Jeopardy Score, was much higher in waterpipe smokers than in cigarette smokers or nonsmokers.⁹⁹ Even those who smoked both cigarettesand water pipe had a lower score than smokers of water pipe exclusively,suggesting that water pipe users have a higher burden of atherosclerotic diseaseresulting from greater use, greater exposure, or greater toxicity of water pipesmoke than cigarette smoke. As with cigarette smokers, water pipe smokers have ahigher propensity for ST-segment-elevation myocardial infarction thannonsmokers, who tend to have non-ST-segment-elevation myocardial infarctionacute coronary syndromes.¹⁰⁵Moreover, water pipe smokers have poorer in-hospital outcomes with highermortality, more frequent myocardial ischemia, and higher recurrent myocardialinfarction rates compared with cigarette smokers. In a prospectivepopulation-based study from Iran, heavy water pipe use was associated with agreater prevalence of heart disease, even when accounting for medication use andcigarette smoking.¹⁰⁶ Fewerstudies have evaluated the association between water pipe smoking and all-causeand cardiovascular mortality. In 1 study from Bangladesh, water pipe smoking wasassociated with higher odds of ischemic heart disease.¹⁰⁷ In another study, there was noassociation between stroke deaths and water pipe smoking.¹⁰⁸ No studies have assessed therelationship between water pipe and stroke risk, although, on the basis of thecontent of the smoke, the risk is anticipated to be at least similar to that ofcigarette smoking. Additional work is warranted to assess the CVD risk burdenassociated with water pipe smoking and the risk of all-cause and cardiovascularmortality in those who smoke water pipes long term.

EFFECTS OF SECONDHAND EXPOSURE TO WATER PIPE TOBACCO SMOKE

As has been found with those exposed to cigarette smoking, individualsexposed to secondhand water pipe tobacco smoke and residual matter from water pipeuse (ie, third-hand smoke) are at risk for negative health outcomes.^6,109 Numerous studies have examined the environmental andhealth effects of secondhand exposure to water pipe tobacco smoke in variousgeographic regions, including the United States, Canada, the United Kingdom, Russia,India, and the eastern Mediterranean region.^110–115 Interms of environmental air quality indicators, a primary outcome typically assessedis the level of PM_2.5^,116 a known cardiovascular risk agent.¹¹⁷ Although outdoor PM_2.5(originating primarily from fossil fuel combustion) is not directly comparable to PMgenerated from water pipes or other tobacco products, PM concentrations are commonlyused to index the presence of secondhand smoke more generally.¹¹⁸

Significantly elevated PM₂₅ levels have been detected in waterpipe cafés/bars or places with high water pipe smoke density (349μg/m³).^{110,112,114,119,120} Although PM levels associated with waterpipe smoke vary with the number of individuals smoking, building size/dimensions,and ventilation characteristics, PM_2.5 concentrations of 287,¹²¹ 400,¹²² 1420,¹¹⁹ and 1 180¹²³ μg/m³ have been reported at differentlocations. In each study, the levels of PM_2.5 in the bars were higherthan in the ambient air outside the bar, but the levels of PM_2.5 werehigher in locations near the water pipe bars, suggesting that PM_2.5 fromwater pipe bars could elevate PM_2.5 levels in the vicinity of theseestablishments.¹²¹ ThePM₂₅ concentrations reported in many of these studies have been citedto exceed the air quality guides set by the Environmental Protection Agency (annualmean, 12 μg/m³; 24-hour average, 35 μg/m³).Nevertheless, the composition of the tobacco smoke and therefore its health effectsare likely to be quite different from typical ambient air pollution from fossil fuelcombustion, making it difficult to assess the health impact of water pipe emissionsrelative to ambient pollution.

In addition to PM, secondhand water pipe smoke contains other potentiallyhazardous constituents such as CO, nicotine, tobacco-specific nitrosamines, andPAHs. Significantly higher levels of ambient CO were observed inside water pipebars/restaurants (7.3±2.4 mg/m³) in London, United Kingdom,relative to levels measured outside these venues (0.9±0.7μg/m³).¹²¹Results from a study of the home environments of daily water pipe smokers indicatedsignificantly higher levels of air-based nicotine and surface-based nicotinecompared with nonsmoking homes. In addition, urinary levels of nicotine metabolites(cotinine), tobacco-specific carcinogenic nitrosamine [nitrosamine4-(methylnitrosamino)-1-(3-pyridyl)-1-butanol], and acrolein (3-hydroxypropylmercapturic acid), a respiratory and cardiovascular toxicant, were significantlyhigher among children living in daily water pipe smoking homes, reflectingsecondhand smoke exposure.¹²⁴There are few reports of direct health effects associated with secondhand water pipesmoke exposure. Two studies performed in Lebanon indicated that occupational orhome-based exposure is associated with negative respiratory symptoms (eg, wheezing,chronic cough).^125,126 Taken together, this body of work suggeststhat secondhand water pipe smoke may expose individuals, particularly children andthose who work in the water pipe hospitability industry, to several types of waterpipe-associated toxic exposures and potential health risks. Although there are nospecific data detailing the relationship between secondhand water pipe smoke andchronic disease progression or mortality, similarities to evidence for secondhandcigarette smoke exposure suggest a similar risk profile.^118,127

CESSATION OF WATER PIPE TOBACCO SMOKING

Approximately one-quarter to one-half of water pipe tobacco smokers in theUnited States and Middle East want to quit, including youth and youngadults.³² Across severalpopulations, 25% to 75% of those who want to quit make a quit attempt eachyear.^128–132 Individuals interested inquitting are more likely than those not interested in quitting to believe that waterpipe smoking damages health,^32,133,134 are less nicotine dependent,^130,133,135 are more likely to have receivedphysician advice to quit,¹³⁶ andhave family or friends who disapprove its use.^130,133,136 In a study from Syria, most water pipetobacco smokers who sought cessation treatment smoked at least 6 times per week, hadsmoked for several years, and made at least 1 previous unsuccessful quitattempt.¹³⁷ Thedevelopment of cessation interventions for water pipe tobacco use, both behavioraland pharmacological, is in its infancy. An expert consensus panel evaluated a widerange of behavior change techniques deemed to be relevant for supporting water pipesmokers to quit.¹³⁸ The panelachieved moderate to strong agreement on 3 broad categories: preparation andplanning to quit (eg, assessing readiness to quit and previous quit attempts andfacilitating identification of barriers to cessation and problem solving),increasing awareness of harms of water pipe smoking and advantages of quitting (eg,providing information on the consequences of smoking and cessation, assessing thepros and cons of quitting and not quitting), and relapse prevention and sustainingex-smoker identity (eg, assessing and providing information on withdrawal symptomsand facilitating relapse prevention).

Systematic reviews of the impact of cessation interventions for water pipesmokers identified 5 randomized or cluster-randomized controlled studies that testedbehavioral or pharmacological approaches.^139,140 All 5 studiesshowed unclear or high risk of bias on key indicators such as blinding and selectiveoutcome reporting. Two studies showed significantly higher quit rates in theintervention group. In Pakistan, Dogar and colleagues¹⁴¹ conducted a secondary analysis of a largecluster-randomized cessation trial that enrolled 1955 patients from 33 healthcenters who had suspected pulmonary tuberculosis and smoked water pipe orcigarettes. Health centers were randomized to provide 1 of 3 treatments: behavioralsupport (2 brief consultations that included preparing for the quit day, encouragingviewing oneself as a nonsmoker, and reviewing progress, consistent withrecommendations by O’Neill et al¹³⁸), behavioral support plus 7 weeks of treatment withbuproprion, and usual care. Among the 215 water pipe–only smokers, 6-monthquit rates were higher among those who received behavioral support compared withthose who received usual care (45.7% versus 20.3%, respectively; adjusted relativerisk, 2.5 [95% CI, 1.3–4.8]) and among those who received behavioral supportplus buproprion compared with those who received usual care (50.0% versus 20.3%,respectively; adjusted relative risk, 2.2 [95% CI, 1.3–3.7]). Acommunity-based cluster trial conducted in Egypt randomized villages to receive abehavioral intervention consisting of several community health promotion activities(eg, school prevention efforts, antismoking education in mosques and churches, peereducators) or no intervention.¹⁴²Men in intervention villages who were current water pipe smokers at baseline weremore likely to no longer smoke at 12 months after treatment than men in controlvillages (relative risk, 3.3 [95% CI, 1.4–8.9]; calculated by Jawad etal¹³⁹).

Three other small randomized trials found positive but nonsignificanteffects of behavioral interventions, including a single-session educationalintervention delivered as a PowerPoint presentation to US collegestudents,⁶¹ a multisessionschool-based intervention in Lebanon and Qatar,¹⁴³ and a multicomponent, physician-delivered, one-on-onebehavioral intervention among Syrian adults.¹³⁷ Another small trial of 109 US water pipe cafécustomers who were randomized to a brief, single session of health risk informationand personalized feedback about expired CO levels versus an assessment-only controlfound that ≈45% of subjects in both conditions reported no water pipe use at3 months after treatment.¹⁴⁴

Most evaluations of water pipe cessation to date are pilot studies, usuallywith only small sample sizes, short follow-up periods, no biochemical verificationof abstinence status, and nonrandomized designs.¹³⁹ From these studies it appears that certainbehavioral strategies that have proved effective for cigarette cessation may beuseful when adapted for water pipe cessation. These techniques include educating thesmoker about the health consequences of water pipe use, increasing motivation toquit by reviewing the pros and cons of smoking and quitting, setting and preparingfor the quit day, and providing coping assistance to prevent relapse. Data fromcontrolled trials are not yet available to determine the efficacy of pharmacologicalinterventions, but a double-blind randomized controlled trial is underway to testthe efficacy of varenicline for water pipe cessation.¹⁴⁵

OVERALL SUMMARY

The data reviewed here support several conclusions:

Water pipe tobacco smoking is prevalent worldwide, especially amongyouth and young adults. Most users in Western countries smoke water pipeintermittently. Many water pipe users concurrently use other forms oftobacco products.
The spread of water pipe tobacco smoking is promoted by severalfactors, including sweetened and flavored water pipe tobacco, social mediathat promotes this method of tobacco use, and misperceptions about itsaddictive potential and adverse health effects.
A majority of users believe that water pipe tobacco smoking is lessharmful than cigarette smoking, that the probability of addiction is low,and that quitting water pipe tobacco smoking is not difficult.
The risk of initiation of cigarette smoking may be higher amongwater pipe smokers than among never smokers.
The level of nicotine to which water pipe tobacco smokers areexposed has been demonstrated to be physiologically active in the shortterm⁹⁴ and canproduce dependence with repeated exposure.¹⁴⁶
While direct comparisons have some limitations, compared withsmoking a single cigarette, a single session of water pipe smoking typicallyresults in greater exposure to CO. The CO levels to which water pipe usersare exposed can produce toxicity with short-term exposure at high levels andinterfere with exercise capacity.
The smoking behavior associated with water pipe tobaccosmoking—sessions lasting ≥30 minutes and involving theinhalation of many liters of smoke—can result in water pipe smokersinhaling substantial quantities of toxicants during each useepisode.^147,148 Water pipe smokecontains high levels of PM, which contains smaller particles at higherconcentrations than cigarettes. Comparing a single cigarette with a singlewater pipe session shows that water pipe use exposes smokers tosignificantly higher levels of heavier and more toxic PAHs than cigarettesmoking, as well as cardiorespiratory toxicants such as volatile organiccompounds and heavy metals such as cadmium and lead that can injure theblood vessels and the brain.
Although evidence for water pipe–attributable disease is notas robust as the evidence for cigarette smoking, a growing number of studiessuggest that water pipe tobacco smoking is a risk factor for pulmonarydisease and CVD.

KNOWLEDGE GAPS

There are many knowledge gaps on the subject of water pipe tobacco smokingthat provide opportunities for more rigorous studies evaluating the link betweenthis form of tobacco smoking and a variety of disease outcomes, including CVD andstroke. Conducting such studies is challenging because the regions where frequentand long-term water pipe tobacco smoking is most prevalent often lack the resourcesrequired for large-scale epidemiological studies. In addition, the frequency of dualuse of waterpipe and cigarettes can make identifying the specific effects of waterpipe tobacco smoking more difficult. Additional work is needed to test and developempirically supported, water pipe–specific cessation interventions. It wouldalso be beneficial to test both behavioral and pharmacological methods to promotecessation in adequately powered randomized controlled trials using standardizedoutcome criteria, including adequate follow-up durations, biochemical verificationof abstinence, intention-to-treat analysis to maintain prognostic balance when lossto follow-up occurs, and blinded follow-up assessment.¹³²

Opportunities also exist to address knowledge gaps in communication of thehealth effects of water pipe tobacco smoking, cultural influences that may promoteand sustain use across certain population groups, and the development of policiesthat can decrease the likelihood of water pipe–induced dependence, disease,disability, and death among youth worldwide. Currently, there is a persistentmisperception among water pipe users that this method of tobacco use is harmless. Incontrast, many youths are aware of the risks associated with cigarette smoking andavoid that method of tobacco use because of those risks.

Further research is needed to determine how best to communicate to youththat the same toxicants that are present in cigarette smoke are present in waterpipe smoke and that any individual who avoids cigarette smoking to avoid inhalinglethal chemicals should avoid water pipe tobacco smoking for the same reason. Thiseffort may require a transdisciplinary approach in which health communicationscientists work with other investigators who are familiar with water pipe smoketoxicant content, user toxicant exposure, and disease risk to craft messages thatare accurate and meaningful to the target audience. The information for suchmessaging is available now to inform public health policy, planning, andpractice.

There are also important knowledge gaps in policies that might be mosteffective in curtailing the worldwide spread of water pipe tobacco smoking. Forexample, although considerable effort has been spent in developing and evaluatingeffective policies on cigarette taxation, labeling, advertisement, availability, andother factors, little policy-related research has addressed water pipe tobaccosmoking. Many of the same policy interventions are likely to be relevant to waterpipe smoking and could be readily adapted to address this form of tobacco use,although additional innovation may be warranted. For example, because water pipetobacco smoking often occurs in dedicated commercial venues where the water pipetobacco is handled by staff rather than by user (ie, water pipe bars), these venuescould be taxed (in addition to the tobacco itself). Health warning labeling could beextended to these venues (eg, required graphic health warning signage in each venue)and, in addition to tobacco packaging, to the water pipe itself. However,identification of the characteristics and evaluation of the effectiveness of suchstrategies require empirical study.

SUGGESTIONS FOR CLINICAL PRACTICE

To identify and treat water pipe tobacco smokers in clinical settings,healthcare providers are encouraged to do the following:

Ask users about water pipe use and frequency explicitly, using avariety of terms if necessary, as well as use of other tobacco products, aspart of routine clinical examinations.
Advise users to quit water pipe and other tobacco product use.
Assist water pipe smokers to quit by providing cessation counseling,including setting a quit date and providing social support and copingassistance.
Refer water pipe smokers to credible sources for information onpotential addictiveness and health consequences of water pipe use, includingthis statement.

Acknowledgments

This statement was approved by the American Heart Association ScienceAdvisory and Coordinating Committee on November 1, 2018, and the American HeartAssociation Executive Committee on November 27, 2018. A copy of the document isavailable athttps://professional.heart.org/statements by using either“Search for Guidelines & Statements” or the “Browse byTopic” area. To purchase additional reprints, call 843–216-2533 ore-mailkelle.ramsay@wolterskluwer.com.

The American Heart Association requests that this document be cited asfollows:

Bhatnagar A, Maziak W, Eissenberg T, Ward KD, Thurston G, King BA, SutfinEL, Cobb CO, Griffiths M, Goldstein LB, Rezk-Hanna M; on behalf of the AmericanHeart Association Behavioral Change for Improving Health Factors Committee of theCouncil on Lifestyle and Cardiometabolic Health and Council on Epidemiology andPrevention; Council on Cardiovascular and Stroke Nursing; Council on Quality of Careand Outcomes Research; and Stroke Council. Water pipe (hookah) smoking andcardiovascular disease risk: a scientific statement from the American HeartAssociation.Circulation. 2019;139:e917-e936. doi:10.1161/CIR.0000000000000671.

The expert peer review of AHA-commissioned documents (eg, scientificstatements, clinical practice guidelines, systematic reviews) is conducted by theAHA Office of Science Operations. For more on AHA statements and guidelinesdevelopment, visithttps://professional.heart.org/statements. Select the“Guidelines & Statements” drop-down menu, then click“Publication Development.”

Permissions: Multiple copies, modification, alteration, enhancement, and/ ordistribution of this document are not permitted without the express permission ofthe American Heart Association. Instructions for obtaining permission are located athttps://www.heart.org/permissions. A link to the“Copyright Permissions Request Form” appears in the second paragraph(https://www.heart.org/en/about-us/statements-and-policies/copyright-request-form).

Disclosures

Writing Group Disclosures

Writing Group Member	Employment	Research Grant	Other Research Support	Speakers’ Bureau/ Honoraria	Expert Witness	Ownership Interest	Consultant/ Advisory Board	Other
Aruni Bhatnagar	University of Louisville	NIH/FDA (PI)^†	None	None	None	None	None	NIH/FDA(salary[principalinvestigator])^†
Caroline O. Cobb	Virginia CommonwealthUniversity	None	None	None	None	None	None	None
Thomas Eissenberg	Virginia CommonwealthUniversity	NIH (PI and coinvestigator onvarious grants)^†	None	None	None	None	None	None
Larry B. Goldstein	University of Kentucky	None	None	None	None	None	None	None
Merlyn Griffiths	University of NorthCarolina–Greensboro	NIH (grant $420 830project)^†	None	None	None	None	None	None
Brian A. King	Centers for Disease Control andPrevention, Office on Smoking and Health	None	None	None	None	None	None	None
Wasim Maziak	Florida InternationalUniversity	None	None	None	None	None	None	None
Mary Rezk-Hanna	UCLA School of Nursing	None	None	None	None	None	None	None
Erin L. Sutfin	Wake Forest School of MedicineSocial Sciences and Health Policy Medical Center	NIH (PI and coinvestigator onseveral NIH-funded grants)^†	None	None	None	None	None	None
George Thurston	New York University School ofMedicine	None	None	None	None	None	None	None
Kenneth D. Ward	University of Memphis School ofPublic Health	None	None	None	None	None	None	None

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This table represents the relationships of writing groupmembers that may be perceived as actual or reasonably perceivedconflicts of interest as reported on the Disclosure Questionnaire,which all members of the writing group are required to complete andsubmit. A relationship is considered to be“significant” if

the person receives $10 000 or more during any12-month period, or 5% or more of the person’s gross income;or

the person owns 5% or more of the voting stock or share ofthe entity or owns $10 000 or more of the fair market valueof the entity. A relationship is considered to be“modest” if it is less than“significant” under the preceding definition.

^†

Significant.

Reviewer Disclosures

Reviewer	Employment	Research Grant	Other Research Support	Speakers’ Bureau/ Honoraria	Expert Witness	Ownership Interest	Consultant/ Advisory Board	Other
Neal L. Benowitz	University of California, SanFrancisco	NIH^†; Flight AttendantMedical Research Institute^†; California Tobacco Related DiseaseResearch Program^†	None	None	None	None	Pfizer^*	None
Debabrata Mukherjee	Texas Tech University	None	None	None	None	None	None	None
Mariann R. Piano	Vanderbilt University	None	None	None	None	None	None	None

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This table represents the relationships of reviewers thatmay be perceived as actual or reasonably perceived conflicts ofinterest as reported on the Disclosure Questionnaire, which allreviewers are required to complete and submit. A relationship isconsidered to be “significant” if

^(a)

the person receives $10,000 or more during any 12-monthperiod, or 5% or more of the person’s gross income; or

^(b)

the person owns 5% or more of the voting stock or share ofthe entity, or owns $10,000 or more of the fair market value of theentity. A relationship is considered to be “modest” ifit is less than “significant” under the precedingdefinition.

Modest.

^†

Significant.

Footnotes

Disclaimer: The findings and conclusions in this report are those of theauthors and do not necessarily represent the official position of the US Centersfor Disease Control and Prevention.

The American Heart Association makes every effort to avoid any actual orpotential conflicts of interest that may arise as a result of an outsiderelationship or a personal, professional, or business interest of a member ofthe writing panel. Specifically, all members of the writing group are requiredto complete and submit a Disclosure Questionnaire showing all such relationshipsthat might be perceived as real or potential conflicts of interest.

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Movatterモバイル変換

PERMALINK

Water Pipe (Hookah) Smoking and Cardiovascular DiseaseRisk

Aruni Bhatnagar,PhD, FAHA

Chair Wasim Maziak,PhD

Thomas Eissenberg,PhD

Kenneth D Ward,PhD

George Thurston,ScD

Brian A King,PhD, MPH

Erin L Sutfin,PhD

Caroline O Cobb,PhD

Merlyn Griffiths,PhD

Larry B Goldstein,MD, FAHA

Mary Rezk-Hanna,PhD

Abstract

DESIGN AND OPERATION

Figure 1. A typical water pipe and its main components.

EPIDEMIOLOGY

Patterns of Water Pipe Smoking Among Youth

Prevalence of Use

Trends in Use

International Use

Characteristics of Water Pipe Smoking Among Youth

Flavored Use

Frequency of Use

Polytobacco Use

Reasons for and Perceptions About Water Pipe Smoking Among Youth

Reasons for Use

Perceptions About Use

Interest in Water Pipe Smoking

Influence of Social Media

Patterns of Water Pipe Smoking Among Adults

Prevalence of Use

Trends in Use

International Use

Figure 2. Global prevalence of adult water pipe smoking.

Characteristics of Water Pipe Smoking Among Adults

Flavored Use

Frequency of Use

Polytobacco Use

Reasons for and Perceptions About Water Pipe Smoking Among Adults

Reasons for Use

Perceptions About Use

WATER PIPE SMOKE CONSTITUENTS

Figure 3. Approximate abundance of harmful or potentially harmful substances in waterpipe tobacco smoke relative to standard cigarette smoke.

Nicotine

Particulate Matter

Carbon Monoxide

Volatile Organic Compounds

Polycyclic Aromatic Hydrocarbons

Heavy Metals and Arsenic

CARDIOVASCULAR EFFECTS OF WATER PIPE SMOKING

Figure 4. Potential constituents of water pipe tobacco smoke and their associatedcardiovascular effects.

Cardiovascular Effects of Short-Term Water Pipe Smoking

Cardiovascular Effects of Long-Term Water Pipe Smoking

EFFECTS OF SECONDHAND EXPOSURE TO WATER PIPE TOBACCO SMOKE

CESSATION OF WATER PIPE TOBACCO SMOKING

OVERALL SUMMARY

KNOWLEDGE GAPS

SUGGESTIONS FOR CLINICAL PRACTICE

Acknowledgments

Footnotes

REFERENCES

ACTIONS

PERMALINK

RESOURCES

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