Something Falsely Reported. False Information

[Teissenb]

Looks like my links got blocked by VCU. Sorry. Let's try these:

PAHs: [url="http://www.ncbi.nlm.nih.gov/pubmed/18308445?itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVDocSum&ordinalpos=8"]http://www.ncbi.nlm....um&ordinalpos=8[/url]

Volatile aldehydes: [url="http://www.ncbi.nlm.nih.gov/pubmed/18834915?itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVDocSum&ordinalpos=5"]http://www.ncbi.nlm....um&ordinalpos=5[/url] Edited December 20, 2009 by Teissenb

[Sonthert]

[quote name='Teissenb' date='20 December 2009 - 04:23 AM' timestamp='1261308231' post='440525']
Hey Eric.

Thanks for preparing that stuff for us -- we look forward to starting our project. I just now sent you a PM with the actual paper that the abstract I linked to describes. As you'll see, we are talking BLOOD levels of CO and nicotine -- this is the first controlled study to ever compare cigarette and hookah in terms of their ability to raise smokers' blood levels of CO and nicotine. The results are as I said: three times the CO and 1.7 times the nicotine (this is comparing a single 45-minute hookah session with a single ~5-minute cigarette, the unit of analysis being the "smoking episode"). Note that, relative to the cigarette, CO levels were higher after only 5 minutes of hookah smoking .

As for tar, it is not a matter of interpretation or language. There is a legal definition. Here is one of many links/documents that tells you that tar is nicotine free dry particulate matter (or, anything in smoke that is not nicotine or water):

[url="http://legacy.library.ucsf.edu:8080/q/e/x/qex13d00/Sqex13d00.pdf"]http://legacy.librar...0/Sqex13d00.pdf[/url]

here is another (see definition 3.5)

[url="http://www.hc-sc.gc.ca/hc-ps/alt_formats/hecs-sesc/pdf/tobac-tabac/legislation/reg/indust/method/_main-principal/nicotine-eng.pdf"]http://www.hc-sc.gc....icotine-eng.pdf[/url]

So, if you accept that "tar" is NFDPM (i.e., everything in smoke that is not nicotine or water) then of course hookah smoke has "tar". Hookah smoke has things in it that are not nicotine or water. For instance, it has all of the products of charcoal combustion, because there is charcoal smoke that is being dragged past the tobacco.

Why is hookah smoke smoke? Because it has combustion products in it (at the very least, charcoal combustion products). CO is the giveaway here. Is it vapor and not smoke? Well, it has a gas phase and a particle phase. If we agree that gas = vapor, then YES some of it is vapor. Some of it is also particle. The tar is everything in the particle phase that is not water or nicotine. Also the smoke contains polycyclic aromatic hydrocarbons in the particle phase and volatile aldehydes in the gas phase.

PAHs: [url="http://www.ncbi.nlm.nih.gov.proxy.library.vcu.edu/pubmed/18308445?itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVDocSum&ordinalpos=8"]http://www.ncbi.nlm....um&ordinalpos=8[/url]
Volatile aldehydes: [url="http://www.ncbi.nlm.nih.gov.proxy.library.vcu.edu/pubmed/18834915?itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVDocSum&ordinalpos=5"]http://www.ncbi.nlm....um&ordinalpos=5[/url]

Does hookah smoke differ from cigarette smoke? ABSOLUTELY! The charcoal and the different temperatures at which the two forms of tobacco are heated guarantee differences. HOW are they different? In many ways that we do not yet know, I am certain. What we do know is that the levels of some PAHs are never less than and, for some PAHs, 20-200 HIGHER in hookah smoke than in cigarette smoke (link above). As you noted, the heavy metal content differs. While you may not be impressed by the absolute finding of 6,870 ng of lead in the smoke produced by a single waterpipe use episode, I am impressed by the fact that this level of lead content is several orders of magnitude greater than in a cigarette. When you consider the known adverse effects of chronic lead exposure on the developing brain, and also that there are threads on this very forum devoted to whether or not a forum member should facilitate a 12 year old's interest in hookah smoking, I hope you can see how 1000 times greater lead levels are a concern. If you cannot, then I will convince you of nothing.

With regard to machine smoking tests, I value their results to determine smoke toxicant yield (what is in the smoke), and always prefer to follow up with studies in humans to determine smoke toxicant exposure (what is in the smoker). I would not say that machine smoking tests of smoke yield are flawed, but would agree that they are best when complemented by parallel studies of smoker exposure. FYI, we have tested the blood nicotine levels of hookah smokers using almost every widely available hookah tobacco product, and, to the best of my recollection EVERY ONE OF THEM delivers nicotine to the hookah smokers (SOEX does not -- that is the only non-tobacco preparation that we have tested). When my university opens up again in the new year, I will try to get you a list of brands tested and whether or not they deliver nicotine. I would be very surprised to find a popular brand that does not deliver nicotine. I would be very interested in getting from you a list of the so-called "washed" versus "unwashed" brands, because I personally doubt there is a difference in smoker nicotine exposure between the two types but would like to test the hypothesis and be proved wrong.

LD50s have no place in this conversation as they assess acute toxicity and we are discussing chronic exposure. What we should be discussing is relative risk, as in (fact) cigarette smokers have a 10-20 times greater chance of getting lung cancer and dying form lung cancer than non smokers. There are similar elevated risks of other disease like cardiovascular disease, lung disease, and other cancers. You know this, I am sure. So, you want the same relative risk numbers for hookah smoking, right? Me too. Those kind of numbers take decades of carefully controlled epidemiological research that, for hookah, has not been done. To be very clear:

Is the risk of a hookah smoker dying of lung cancer greater than, equal to, or less than a non-smoker? We don't know.
Is the risk of a hookah smoker dying of cardiovascular disease greater than, equal to, or less than a non-smoker? We don't know.
Is the risk of a hookah smoker dying of lung disease greater than, equal to, or less than a non-smoker? We don't know.

What we do know, beyond a shadow of a doubt, is that hookah smoke contains cancer-causing PAHs, cardiovascular disease-causing CO, and lung-disease causing volatile aldehydes. It also contains the nicotine that can cause the dependence that can keep people inhaling these toxicants even when the people want to stop and try to stop. We also know beyond a shadow of a doubt that hookah smokers are exposed to CO and nicotine, and we have no reason to believe that they would be exposed to these toxicants and not PAHs and volatile aldehydes. So, my conclusion from all of this is that, while we are waiting for the epidemiologists to do their thing, we should be aware that hookah smoking, by virtue of the toxicants in the smoke and in the smoker, is almost certainly associated TO SOME DEGREE with diseases as cigarette smoking, and hookah smokers are elevating their risks for these diseases by some unknown multiplier that is greater than 1.0

I believe, based on the best evidence to date, that this statement is true. That doesn't mean I also want to ban hookahs or hookah smoking. I would like hookah smokers to be informed about the risks of this behavior and I hope that, based on this information, they will stop smoking voluntarily before death or disease makes that choice for them.

Tom E.
[/quote]

Thanks for the followup, Tom.

I'm not denying that hookahs have tons of tar, what I am questioning is the relative risks of that "tar", in relation to cigarette "tar". My estimation is, correct me if I 'm wrong, that the hazardous components in cigarette "TAR" are greatly diluted in Hookah smoke/vapor "TAR". The definition is fine, but comparing hookah smoke on a 1:1 basis is deceptive if the critical constituents are far more dilute in hookah smoke. If they were 90% as high, then thats one thing, but were talking at least and order of magnitude or two, I would imagine. As an example, there is the same amount of sodium in a slice of white bread as in a bathtub full of softened water. You could safely say, by definition, that they both contain sodium. The study is talking about volume, that is more dilute. The argument is left hanging that hookah smoke contains 48 (or 65 times...whatever the number is) times the amount of volume and contains hazardous chemicals. In the same sense, a bathtub of soft water contains 20000 times as much material as a slice of bread and contains sodium. The volume is quite a bit larger, and it contains the "deadliest additive in food". Lets talk about actual amounts of hazardous chemicals and save comparisons of volume. Hookah smoke is more dilute, so comparing the amount of tar on a 1:1 basis is, forgive me, a little shady. I'm not denying that these things exist, I'm questioning the extent. I got the CO and the like and will examine the PAH content here in a little while. I hope I'm not shocked, though.

The age-old riddle is what weighs more...a ton of lead or a ton of feathers? There are certainly 65 times as much feathers as lead...so the feathers?

In terms of nicotine, though, a number of studies I have read offer that the habituation in hookah smoking is far, far lower than it is for cigarettes. Cigarette companies came up with a bright idea to add ammonia to cigarettes to make them more addictive. I personally don't add ammonia to my product, so I can't imagine that the nicotine level in my hookah tobacco being compared to the nicotine level in cigarettes on a 1:1 basis is fair, again. I don't know how effective ammonia is to the absorption of nicotine in the body. If its minuscule, I might be hanging off a cliff with my tail tied to a daisy. What sorts of data is there to adjust ammonated tobacco to non-ammonated tobacco? How much more addictive are cigarettes with ammonia added than a cigarette without any treatment?

I should also ask why you didn't compare smoking hookah for 45 minutes and smoking cigarettes for 45 minutes. This would be a fair comparison, in my estimation, unless you want to concede that hookah smoking doesn't, on a 1:1 basis compare with cigarettes.

I'm not advocating the practice, but hookahs can be smoked with electrical heating elements. You are attributing the risk to smoking a hookah...should we be talking about the risks of crummy charcoal instead? How many/how much of the health effects aren't attributable to the tobacco, but the charcoal? If the goal is to inform people about the risks of smoking hookah, shouldn't it be a priority to identify what part of the system is the risk (or the lion-share of the risk) and come with alternatives to reduce the risks posed by the most problem parts? Tobacco is the scapegoat here, its all tobaccos fault, but if we could come up with a better process, perhaps we can minimally protect the health of the smokers of hookah tobacco. For instance, if you told me that 90% of the chemicals in hookah smoke came from the hose, I could design a safer hose that minimized those effects. I'm willing to do it for my customers. If it will protect one person from taking a stupid, pointless risk, I'm on board with you.

The claim is made that hookah smoke contains particulate matter, this is what makes it smoke...if the particulate matter isn't from the tobacco, it isn't tobacco smoke. Yes, I know it seems like hair splitting, but we're trying to clear this question up elsewhere. A raincloud has water vapor, liquid droplets of water and dust particulate in it...is it smoke then? I guessing no, since the particulate didn't come from the raincloud, it came from elsewhere, its a contaminant. I know I'm out on this ledge a mile, here, trust me...

In terms of washed and unwashed tobaccos, nicotine is water soluble, its solubility curve is inverted and begins to fall off after 60C, I believe. Some manufacturers treat their water with acetic acid (AKA vinegar) to theoretically wash even more nicotine out. Several of the unwashed brands are lower nicotine tobaccos to begin with, so the distinction may be a little fuzzy. Nic. levels in unprocessed tobacco range from about .8% to 5%. Nakhla, for instance, has a nicotine level, based on a known quantity like Tangiers, of somewhere around .15%, Tangiers being around .4%. I would imagine that washing the nicotine out would reduce it about two orders, so a washed Tangiers variety would be around .004%. I have absolutely no scientific data to back this up. I can't imagine that the nicotine reduction would be less than one order of magnitude (1/10). It certainly wouldn't remove all of it. One scientific experiment I read about noted that a dry control test had traces of nicotine already in it...implying deposition of nicotine in areas of the hookah that couldn't be cleaned.

LD50s would be a gross dose estimation. I use it only because it is commonly available and it would presumably follow chronic exposure risks. A hookah has 1000 times the amount of lead as a cigarette? OK, I'll accept that on the face of it for the sake of discussion. Is the amount of lead from a cigarette significant? How much? What are chronic exposure thresholds in relation to cigarette smoke? Nice one. You might not be able to convince me of anything. You've convinced me of that at least. Its a matter of scale again. You may have the number to show that the lead content of cigarettes is alarmingly dangerous, therefore 1000 times that amount is shocking. If the amount of lead in cigarettes is insignificant, however, 1000 times that amount might be significant or insignificant. Also, again, is the content of the lead evolving from the charcoal or the tobacco? I can't imagine it would be from the tobacco, I would look at the lead content of the charcoal. Perhaps we can devise a risk chart for different types of charcoals based on their lead content? Again, I want to find ways to make smoking hookah as safe as reasonably possible. If charcoal are to blame, lets address that. If there's something I can do to make Tangiers safer, I'm on board with you. If I make changes, and they are important to people, then other brands may follow suit, and if there is a god, I would pray that they would.

Most of the people I've known that have switched from cigarettes to hookah have noted a decline and, in most cases, an elimination of chronic smoker's symptoms. The other question is decoupling smokers of exclusively hookah from smokers of exclusively cigarettes vs. people that smoke both. Like I said, I will read your paper and see if these questions are answered.

You offer the thought that nicotine increases addictiveness. That makes sense, I'm sure, but you also proffer that people are somehow "snared" in this addiction cycle. From a purely philosophical point of view, you don't believe that people can overcome addiction with determination? I call it the puppet philosophy: that people are puppets of external influences, like addiction. I don't subscribe to it, personally.. You don't believe that people bear the responsibility of continuing to smoke cigarettes (or hookah)? They really can't control themselves? Would it also follow for child molesters or chronic gamblers? I would offer that people should be held individually responsible for their actions and despite external influences or individual appetites still bear that responsibility. I don't believe alcoholics or child molesters are "sick" I think they undertake highly questionable, immoral activities or do something excessively. What are your philosophical views on this?

[Zinite]

I love that every once in awhile we can have an intelligent discussion about these things.

[Teissenb]

Eric:

Based on my research and that of others, the data indicate that ml for ml, hookah smoke has less nicotine and CO and (almost certainly) tar than cigarette smoke. HOWEVER, this statement is largely irrelevant in the context of the same data that show that hookah smokers, on average, inhale ~100 times as much smoke during a single hookah session as a cigarette smoker does in a single cigarette. That is precisely why, even after only 5 minutes of smoking in the waterpipe/cigarette study that I sent to you, CO levels were significantly higher in the waterpipe condition as compared to the cigarette condition.

In my view, addiction/dependence alters brain chemistry such that, without the drug, stimuli formerly experienced as pleasant are now experienced as less pleasant (I take this view based on a paper published in Science by George Koob and Michel LeMoal in 1997). I am unsure if a lifetime of subsequent drug abstinence alters the chemistry again, back to the baseline state. I am sure that the altered experienced can be "managed" (for lack of a better term) by a variety of methods, including "will power", behavioral therapy, and/or pharmacotherapy.

Ammonia or no ammonia, the data are clear: a single hookah session delivers more nicotine than a single cigarette. There have been plenty of posts on this forum from self-aware people who have acknowledged that their hookah use has made them tobacco/nicotine dependent. Whether they know it or not, the describe the classic pattern: occasional use followed by regular use followed by daily use followed by frequent use every day. They describe that they did not intend for this increase to occur and are sorry that it did. Some have trouble quitting. That is dependence.

I have no data comparing charcoal and electric heat sources but I am willing to bet that the smoke toxicant content would be lower with an electric heater (I also am not advocating the practice). I also would bet that hookah smokers will find electric heaters less acceptable.

Tom E.

[demonix]

[quote name='Zinite' date='20 December 2009 - 07:03 PM' timestamp='1261361004' post='440643']
I love that every once in awhile we can have an intelligent discussion about these things.
[/quote]

I agree. I've tried to have a couple of these arguments in a couple classes of mine, but never pushed them too far because I don't know all my facts, but generally I know more than the other person.

If I ever need someone to help back me up on the subject, I'll just fly Eric up to one of my classes and have him preach lol

[Sonthert]

[quote name='Teissenb' date='21 December 2009 - 03:25 AM' timestamp='1261391109' post='440709']
Eric:

Based on my research and that of others, the data indicate that ml for ml, hookah smoke has less nicotine and CO and (almost certainly) tar than cigarette smoke. HOWEVER, this statement is largely irrelevant in the context of the same data that show that hookah smokers, on average, inhale ~100 times as much smoke during a single hookah session as a cigarette smoker does in a single cigarette. That is precisely why, even after only 5 minutes of smoking in the waterpipe/cigarette study that I sent to you, CO levels were significantly higher in the waterpipe condition as compared to the cigarette condition.

In my view, addiction/dependence alters brain chemistry such that, without the drug, stimuli formerly experienced as pleasant are now experienced as less pleasant (I take this view based on a paper published in Science by George Koob and Michel LeMoal in 1997). I am unsure if a lifetime of subsequent drug abstinence alters the chemistry again, back to the baseline state. I am sure that the altered experienced can be "managed" (for lack of a better term) by a variety of methods, including "will power", behavioral therapy, and/or pharmacotherapy.

Ammonia or no ammonia, the data are clear: a single hookah session delivers more nicotine than a single cigarette. There have been plenty of posts on this forum from self-aware people who have acknowledged that their hookah use has made them tobacco/nicotine dependent. Whether they know it or not, the describe the classic pattern: occasional use followed by regular use followed by daily use followed by frequent use every day. They describe that they did not intend for this increase to occur and are sorry that it did. Some have trouble quitting. That is dependence.

I have no data comparing charcoal and electric heat sources but I am willing to bet that the smoke toxicant content would be lower with an electric heater (I also am not advocating the practice). I also would bet that hookah smokers will find electric heaters less acceptable.

Tom E.
[/quote]
I must be obtuse or something, Tom. I can't see the connect. If the carbon monoxide levels were equal, for the sake of argument, why does the amount of smoke being 65 times larger matter? If the harmful constituents are more dilute, and we can see that they are, why does 2x, 65x, 48x or 100x as much smoke make a difference? I would have thought that the flat absolute amounts of each contaminant/constituent were what was important. I don't see that drinking 24 Oz. of beer is going to be more intoxicating than drinking 24 Oz. of liquor since the concentrations of one are less than the other. In the same sense, it seems like you are saying drinking 24 Oz. of beer would be worse since there is 8 times more of it than drinking 3 Oz. of liquor, even though, the amounts of alcohol are roughly equivalent. What does the 65 times as much smoke have to do with the hazards in the equation? Your study on blood levels already takes into account the differences in smoke volume or dilution by measuring blood levels?

In a like sense, I'm sure its not linear, but roughly, estimating an equivalent for equal amounts of time of the two items smoked, we could divide the factors by 9 (representing 5 minutes of exposure for smoking a cigarette and 5 minutes of exposure for smoking a hookah), we could roughly approximate that smoking a hookah for the same amount of time as smoking a cigarette (5 minutes, 45 minutes, any equal amount of time) would be hookah smoking has 33% the Carbon Monoxide of smoking cigarettes (3/9=.33 The factor of three times the amount from your study, divided by nine, the factor between the amount of hookah smoking time and the amount of cigarette smoking time) and 19% of the nicotine of smoking cigarettes (1.7/9 = .188). If these are the only critical factors, wouldn't smoking a hookah for an hour be roughly "safer" than smoking cigarettes for an hour? (Thats a lot of butts, though! ) Are all the studies out there that hookah smoking is more dangerous based on skewed amounts of time? What reasoning is there, for instance, in your study to use different exposure times to each? Was is simply to standardize a hookah session to cigarette? How was 45 minutes arrived at as a standard hookah session? Why not 20 minutes or an hour?

I have read studies by Dan Perrin that have said that the addiction cycle can be hardwired into the brain chemistry and that it might never return to its "pre-addiction" state, which is quite alarming, really.

What I was asking is not a scientific sense really, in your experience as a man, on the Earth, do you believe that people are helpless to overcome addiction and they and their actions are effectively controlled by it? Or that the continuing cycle of addiction is due to a lack of willpower/determination/personal responsibility. I'm not a philosopher by training either, but I just wanted to get your view. The tobacco people, of course, often attribute things to free will and/or lack of responsibility. The anti-smoking establishment seem to attribute things to the puppetry of addiction. Not that believing one or the other would paint you in that stripe.

In terms of ammonia, though, I would imagine that the studies that observe a lower incident of dependence in hookah smoking than in cigarette smokers are wrong in your estimation? The cigarette companies add(ed) extra chemicals to their cigarettes to make people want them more (Become more addicted). The design was, correct me if I'm off here, was to make the same amount of nicotine get absorbed faster, spike quicker and drop off more rapidly, making the same amount of nicotine more addictive. I personally don't participate in using those same chemicals cigarette companies do. So on a gram, for gram basis, wouldn't cigarette nicotine be more addictive than Tangiers Hookah nicotine? Agreed, more nicotine in the Tangiers. How significant is the increase of addictiveness in "cigarette" treated tobaccos with ammonia? Is there data to this point?

You have me thinking now, Tom, I've been smoking a lot of hookah recently for all the testing I've been doing. I think I'm going to quit smoking hookah for a week and see what happens. I've been without hookah for several days at a time, but I'm going to try it for a week to see if I notice any dependency symptoms. This should be especially fun, since I had about seven pinches of high-power snuff with AZCoyote today and that stuff seems wicked additive. He got me to do like 12 pinches one day and I was still feeling it the next day and felt a decided drop off in nicotine levels later. Obviously, this doesn't won't prove anything about addiction or the addictive nature of tobacco, I'm just going to try it since you have mental juices flowing here. No tobacco for seven days. Starting after the end of this sentence. Now.

[Teissenb]

Eric:

It was not I that brought up the issue of more dilute smoke: I was responding to an issue that you introduced when you said, in part "Hookah smoke is more dilute, so comparing the amount of tar on a 1:1 basis is, forgive me, a little shady." I am willing to concede that, relative to cigarette smoke, hookah smoke is more "dilute" as you put it: ml for ml, there is less tar in hookah smoke than cigarette smoke. BUT, since the average puff from a hookah is 10 times the volume of the average puff from a cigarette, and, on average, hookah smokers take 10 times the puffs per session as cigarette smokers do per cigarette, the ABSOLUTE yield is as Dr. Shihadeh has described it. There is >30 times the tar in the smoke from a hookah session when compared to the smoke from a cigarette. From the paper I linked to previously you can see that the tar from a single hookah use episode contains cancer-causing polycyclic aromatic hydrocarbons that, in some cases, far exceed (i.e, 20-200 times) levels found in the smoke from a single cigarette. There are also lung-disease causing volatile aldehydes in the smoke, and we have already discussed the CO and nicotine.

You are quite right: by measuring blood levels, we need not worry about whether hookah smoke or cigarette smoke is more dilute . We are focusing on the critical issue of user exposure. Again, with that focus, the conclusion is inescapable: relative to a single cigarette, a single hookah smoking episode is associated with 3 times greater exposure to CO and, over the course of the session, 1.7 times the nicotine.

I would like to point out that the human lung has not evolved to inhale smoke. It is challenged when smoke is inhaled, and the magnitude of that challenge is increased with the volume of smoke inhaled. Surely you can see that inhaling 100 puffs * 500 ml/puff of hookah smoke poses a threat to lung health, and that threat increases as the behavior is repeated?

You asked how we arrived at a 45 minute hookah smoking episode. That is the mean duration of hookah smoking episodes that have been observed in the natural environment and in the laboratory, and also is the mean that has been reported in several surveys. It is a mean, so there is variability to be sure. As I said earlier, even at 5 minutes, our participants had been exposed to more CO when smoking a hookah compared to when smoking a cigarette. 5 minutes. When was the last time you had a 5 minute hookah smoking session?

As for addiction, of course people can overcome it. Some overcome it with will power alone, some overcome it with behavioral therapy, some overcome it with pharmacotherapy. Unfortunately, many people try to overcome addiction and fail. When the addiction is to nicotine, and the delivery system is smoked tobacco via a cigarette, failure to overcome the addiction means a greatly increased chance disability and death. For those people, and there are many of them, their life would have been longer and perhaps better without tobacco. I fear that, in 20 years when the necessary epidemiological research has been completed, I'll write the same sentences about hookah smoking.

I do not have any data on the relative "addictiveness" of cigarettes with or without ammonia. Incidentally, I also don't have any data saying hookah use is more dangerous than cigarette use, and I have never made that claim and I actually do not know anyone who has. The empirically-based statement that I make is this: [font="Default Sans Serif,Verdana,Arial,Helvetica,sans-serif"][size="2"][font="Default Sans Serif,Verdana,Arial,Helvetica,sans-serif"][size="2"]Absent the epidemiological data necessary for a more rigorous conclusion, there is every reason to suspect that at least some of the diseases associated with cigarette smoking (e.g., cancer, lung disease, cardiovascular disease, nicotine dependence) are also associated with waterpipe tobacco smoking, and there may also be some unique risks that arise from the large volume of charcoal smoke inhaled.
[/size][/font][/size][/font]
Tom E.

PS: Do you have a significant other? I'd be very interested in hearing that person's reports of your behavior during your tobacco-free week. Also, keep in mind that, relative to quitting for a lifetime, abstaining for a week is easy. I routinely get 20 cig/day smokers to abstain for 5 days (M-F). Because they know they can smoke again Friday afternoon, they are able to complete the 5 days of abstinence. I'm not meaning to downplay your goal, only to make clear that it is a very different and much more attainable goal than that of a person who wants to quit smoking forever.

[Teissenb]

UPDATE:

Dr. Shihadeh from Lebanon DOES have the data with respect to comparing charcoal and electric heat sources. Here is the abstract (below). If anyone has tried an electric heater, please let me know how acceptable it was to you. Did you like the smoke? Do you still use it?

Abstract from Monzer et al., 2008 (Food and Chemical Toxicology 46, 2991–2995)

Burning charcoal is normally placed atop the tobacco to smoke the narghile waterpipe. We investigated
the importance of charcoal as a toxicant source in the mainstream smoke, with particular attention to
two well-known charcoal emissions: carbon monoxide (CO) and polyaromatic hydrocarbons (PAH). CO
and PAH yields were compared when a waterpipe was machine smoked using charcoal and using an electrical
heating element. The electrical heating element was designed to produce spatial and temporal temperature
distributions similar to those measured using charcoal. With a popular type of ma’assel tobacco
mixture, and using a smoking regimen consisting of 105 puffs of 530 ml volume spaced 17 s apart, it was
found that approximately 90% of the CO and 75–92% of the 4- and 5-membered ring PAH compounds
originated in the charcoal. Greater than 95% of the benzo(a)pyrene in the smoke was attributable to
the charcoal. It was also found that the relative proportions of individual PAH species, the ‘‘PAH fingerprint”,
of the mainstream smoke were highly correlated to those extracted from the unburned charcoal
(R2 > 0.94). In contrast, there was no correlation between the PAH fingerprint of the electrically heated
and charcoal-heated conditions (R2 < 0.02). In addition to inhaling toxicants transferred from the tobacco,
such as nicotine, ‘‘tar”, and nitrosamines, waterpipe smokers thus also inhale large quantities of combustion-
generated toxicants. This explains why, despite the generally low temperatures attained in the
narghile tobacco, large quantities of CO and PAH have been found in the smoke.


[quote name='Teissenb' date='21 December 2009 - 03:25 AM' timestamp='1261391109' post='440709']

I have no data comparing charcoal and electric heat sources but I am willing to bet that the smoke toxicant content would be lower with an electric heater (I also am not advocating the practice). I also would bet that hookah smokers will find electric heaters less acceptable.

Tom E.
[/quote]

[Arcane]

after reading the posts, i can't help be see a slight disadvantage to hookah...you are comparing a so-called "total" exposure from a 45 minute hookah session to a single cigarette? what about the people that smoke 2 cigarettes back to back? why isn't that taken into account? or people like me, who smoked 4-5 cigarettes in one sitting? why weren't people like me or several of my others friends habits considered?

also, why weren't people who only smoke hookah for 15-30 minutes taken into account? there are so many variables or "what if's" to consider...it seems the only equal ground is to do a true 1:1 comparision. either going by time, or by amount of tobacco...not a so-called "session".


so, why aren't studies fighting against hookah doing that kind of comparison? are they aware that their arguments or the "fear" they're trying to instill won't have a bigger impact when the data says, cigarettes appear to expose the consumer far more toxins than hookah when you compare them "equally"?

[Teissenb]

If you were to look at the paper, you would see that we assessed blood CO (technically COHb) and plasma nicotine levels at 5, 15, 30, and 45 minutes after the onset of smoking in both conditions. The five minute time point corresponds to the end of the cigarette. At that time point (5 minutes), the folks in the hookah condition had significantly MORE CO in their blood than when in the cigarette condition, and the amount of nicotine in the blood plasma did not differ across the two conditions at the 5 minute time point. That is at 5 minutes for both. So the time is equal for the hookah and the cigarettes, but the blood CO is greater and the plasma nicotine does not differ. At 5 minutes. For both.

You ask why we compare one hookah use episode to one cigarette: it is because the unit of analysis that interests me is the episode. Here is a formal explanation:

[font="Default Sans Serif,Verdana,Arial,Helvetica,sans-serif"][size="2"]Obviously these tobacco smoking methods differ in amount of tobacco consumed, duration of use, and other features. I acknowledge these differences, and assert that they are precisely the reasons that the two tobacco use methods should be compared in a manner that approximates actual use conditions. Indeed, this position is exemplified in a classic paper (Benowitz et al., 1988) in which the cardiovascular effects and toxicant exposure of 12 puffs from a cigarette (~1 gm) were compared to those of smokeless tobacco (SLT; 2.5 gm, 30 min exposure period). This paper revealed that, relative to a cigarette, SLT is associated with similar nicotine and heart rate increases, but that nicotine and heart rate levels remained elevated for a substantially longer period (see Benowitz et al., Fig 1, p. 24 and Fig 3, p. 26). These results have been central to discussions of the association between SLT use and nicotine dependence and cardiovascular disease (e.g., Henningfield et al., 1997; Winn, 1997), and also have been cited in reference to SLT treatment strategies (e.g., Hatsukami et al., 1992; Severson et al., 2000) and SLT as a tobacco harm reduction method (e.g., Hatsukami et al., 2004). Thus, there is valued precedent for comparing, as we did, the cardiovascular and toxicant exposure of two methods of tobacco use that differ in amount of tobacco consumed, duration of use, and other characteristics. As an aside, ethical considerations would make us extremely reluctant to compare the toxicant exposure of a 45-minute waterpipe tobacco smoking episode with that of 5-10 cigarettes smoked in a similar period of time. Indeed, this frequency of cigarette smoking is relatively abnormal for most cigarette smokers, and such a study, already questionable on ethical grounds, would also have uncertain generalizability.

You are free to conduct other studies using different methodology. I agree that the results may well be interesting.

I thought I explained the 45 minutes -- that is the mean we have observed when watching smokers in cafes in the US and abroad, and that is the mean when smokers report the duration of their episodes to us. Yes, there is variability, some people smoke in shorter sessions and others smoke in longer sessions. That is the thing about the mean: it is an index of central tendency. Again, you could design and conduct a different study where everybody smokes for as long or as short as they want. I chose to do it this way not because I have some nefarious agenda, but because, as a first attempt at understanding the relative toxicant exposure of these two tobacco use methods, it made sense to me. Your mileage may vary.
[/size][/font]
I am not sure why someone might feel that these studies are slanted one way or another. Of course there are other studies that can and will be done. We cannot do every possible study all at once.


[quote name='Arcane' date='21 December 2009 - 01:08 PM' timestamp='1261426084' post='440781']
after reading the posts, i can't help be see a slight disadvantage to hookah...you are comparing a so-called "total" exposure from a 45 minute hookah session to a single cigarette? what about the people that smoke 2 cigarettes back to back? why isn't that taken into account? or people like me, who smoked 4-5 cigarettes in one sitting? why weren't people like me or several of my others friends habits considered?

also, why weren't people who only smoke hookah for 15-30 minutes taken into account? there are so many variables or "what if's" to consider...it seems the only equal ground is to do a true 1:1 comparision. either going by time, or by amount of tobacco...not a so-called "session".


so, why aren't studies fighting against hookah doing that kind of comparison? are they aware that their arguments or the "fear" they're trying to instill won't have a bigger impact when the data says, cigarettes appear to expose the consumer far more toxins than hookah when you compare them "equally"?
[/quote]

[Arcane]

just curious, but how did the study come up with 171 puffs(a near 3 second pull spaced 17s apart) count as a session?

the norm, at least around these forums, is 1-2 pulls per minute. this seems like a significant factor...

[Teissenb]

[quote name='Arcane' date='21 December 2009 - 02:29 PM' timestamp='1261430985' post='440798']
just curious, but how did the study come up with 171 puffs(a near 3 second pull spaced 17s apart) count as a session?

the norm, at least around these forums, is 1-2 pulls per minute. this seems like a significant factor...
[/quote]

From the Sepetdjian et al 2008 paper:

"These puffing parameters were derived from a field study
in which topographies of 52 smokers in a cafe´ in Beirut
were recorded, and represent an ‘‘average” waterpipe
smoking session (Shihadeh et al., 2004)."

Note that in our paper comparing hookah and cigarette toxicant exposure (Eissenberg and Shihadeh, 2009) we observed in U.S. hookah smokers a mean of 71.7 puffs in 45 minutes with a mean interpuff interval of 42.9 seconds. We speculated:

The waterpipe
puff topography data differ from previous reports:
The mean puff volume of 0.8 L is greater than the
approximately 0.5 L reported previously,(25,31) and the
43-second IPI is greater than the previously reported
13–16 seconds.(25,31) These cross-study differences may
reflect differences in study populations: Smokers in
Lebanon and Syria may be more experienced (e.g.,
~30 uses/month),(31) leading to smaller but more frequent
puffs.

You see, nothing nefarious. Different populations may smoke differently. That is why we report these data: so that people like you can ask these questions and hypothesize (reasonably) that different topographies may lead to different toxicant yields (I think everyone would agree that this hypothesis is very reasonable). However, I think reasonable people would also agree that any lifelike topography parameters are likely to demonstrate some level of PAH yield in hookah smoke, and that really is the point: hookah smoke contains these dangerous carcinogens. The more you smoke, the more you get; the more you get, the greater the risk.

[Sonthert]

Yeah, I'll usually smoke a lot more lightly than that. I might take three hits every twenty minutes, but I do it 8 hours a day.

Interesting, on the charcoal. Its what I suspected.

Why are you guys still calling nicotine a toxicant? I like to refer to it as the point of tobacco.

[quote name='teissenb']Eric:

It was not I that brought up the issue of more dilute smoke: I was responding to an issue that you introduced when you said, in part "Hookah smoke is more dilute, so comparing the amount of tar on a 1:1 basis is, forgive me, a little shady." I am willing to concede that, relative to cigarette smoke, hookah smoke is more "dilute" as you put it: ml for ml, there is less tar in hookah smoke than cigarette smoke. BUT, since the average puff from a hookah is 10 times the volume of the average puff from a cigarette, and, on average, hookah smokers take 10 times the puffs per session as cigarette smokers do per cigarette, the ABSOLUTE yield is as Dr. Shihadeh has described it. There is >30 times the tar in the smoke from a hookah session when compared to the smoke from a cigarette. From the paper I linked to previously you can see that the tar from a single hookah use episode contains cancer-causing polycyclic aromatic hydrocarbons that, in some cases, far exceed (i.e, 20-200 times) levels found in the smoke from a single cigarette. There are also lung-disease causing volatile aldehydes in the smoke, and we have already discussed the CO and nicotine.

You are quite right: by measuring blood levels, we need not worry about whether hookah smoke or cigarette smoke is more dilute . We are focusing on the critical issue of user exposure. Again, with that focus, the conclusion is inescapable: relative to a single cigarette, a single hookah smoking episode is associated with 3 times greater exposure to CO and, over the course of the session, 1.7 times the nicotine.

I would like to point out that the human lung has not evolved to inhale smoke. It is challenged when smoke is inhaled, and the magnitude of that challenge is increased with the volume of smoke inhaled. Surely you can see that inhaling 100 puffs * 500 ml/puff of hookah smoke poses a threat to lung health, and that threat increases as the behavior is repeated?

You asked how we arrived at a 45 minute hookah smoking episode. That is the mean duration of hookah smoking episodes that have been observed in the natural environment and in the laboratory, and also is the mean that has been reported in several surveys. It is a mean, so there is variability to be sure. As I said earlier, even at 5 minutes, our participants had been exposed to more CO when smoking a hookah compared to when smoking a cigarette. 5 minutes. When was the last time you had a 5 minute hookah smoking session?

As for addiction, of course people can overcome it. Some overcome it with will power alone, some overcome it with behavioral therapy, some overcome it with pharmacotherapy. Unfortunately, many people try to overcome addiction and fail. When the addiction is to nicotine, and the delivery system is smoked tobacco via a cigarette, failure to overcome the addiction means a greatly increased chance disability and death. For those people, and there are many of them, their life would have been longer and perhaps better without tobacco. I fear that, in 20 years when the necessary epidemiological research has been completed, I'll write the same sentences about hookah smoking.

I do not have any data on the relative "addictiveness" of cigarettes with or without ammonia. Incidentally, I also don't have any data saying hookah use is more dangerous than cigarette use, and I have never made that claim and I actually do not know anyone who has. The empirically-based statement that I make is this: Absent the epidemiological data necessary for a more rigorous conclusion, there is every reason to suspect that at least some of the diseases associated with cigarette smoking (e.g., cancer, lung disease, cardiovascular disease, nicotine dependence) are also associated with waterpipe tobacco smoking, and there may also be some unique risks that arise from the large volume of charcoal smoke inhaled. [/quote]

As to your first paragraph, I follow you better now. Now you have me confused on another point. I was under the impression that vast majority of hookah "smoke" is "tar", since glycerine would qualify as "tar" and glycerine (or PG) would be the overwhelming majority of the "smoke". If the majority of the "tar" in hookah tobacco is glycerine or PG...the "tar" amount isn't too relevant. The smoke quantity may be irrelevant, too? The smoke/"tar" being mostly glycerine/water/PG or whatnot makes the smoke/tar very "non-threatening" and "dilute". I didn't select the word dilute, by the way, it was used in another study on waterpipe. I was using it because it seemed reasonable, would you use a different phrase that you consider more accurate?

The nicotine is going to be one of the first components to boil off (after the water). Therefore, if you test a hookah with a fresh bowl at t=0 -> t=+45 minutes and compare it to a cigarette, I would wager you are going to get markedly different results from if you were to test a hookah from t=+60 minutes -> t=+105 minutes vs. a cigarette. This is slightly specious, of course, on the part of the study, a cigarette is going to be consumed in its entirety in five minutes, so an accurate reading of its components is possible and their effects. The hookah on the other hand, you might only be getting a "slice" of the true picture. So, in terms, if I were to estimate the fat and sugar content in a wedding cake, by only taking half of the top layer, my results might be deceptive. A hookah bowl has a definite lifespan associated with it. I would imagine taking bowls to their completion (when tobacco is obviously beginning to scorch)...thats why I asked why 45 minutes. You might as well compare smoking half a cigarette to smoking an entire cigarette. It will give you a a much more consistent reading on cigarettes. Than smoking half a bowl of hookah will on smoking an entire hookah.

My break-down on spanning the time gap was of course rough, perhaps compare smoking cigarettes for 45 minutes to smoking a hookah for 45 minutes? The first blast from a hookah is going to be inevitably the highest in terms of nicotine, and since there a larger amount of raw tobacco, there would be a larger 'pool' of nicotine to boil. This would, in my opinion, if it were the case (which empirically most hookah smokers will attest to), that the tobacco is vaporizing principally, not burning. A burning event would lead to more uniform production across the entire duration of the event, a vaporizing would show changes as lower boiling point materials declined and were exhausted. This can be shown from some temperature readings I took on a number of bowls. Higher boiling point flavors ran bowls hotter, lower boiling point flavors ran the bowls cooler. The temperatures of the bowls increased throughout the duration of the bowl, up until the point that would be reasonably associated with the glycerine fraction. This is also consistent with the refining of hydrocarbons. The temperature of the mixture increases as lower boiling point materials are exhausted. This is all due to vaporizing. Burning would show relatively constant temperatures. This is also bore out by studies of cigarette burning temperatures.

I have also noted that a number of studies on hookah pipes (especilly ones using puff machines) have the setup partially or entirely hidden. One study I read into had pictures of everything except the bowl with charcoal on. From the description and results, it sounded like they had a mound of charcoal up there. From personal experiments, the degradation of plant material from applying charcoal directly to the raw tobacco, with or without foil as a buffer is far different than the amount of degradation (none to nearly none) of hookah tobacco when heat is applied to it through foil. The study noted degradation to the plant material, still very slight.

Did you send me data on the cancer rates in pipe or cigar smokers in relation to cigarette smokers? When we spoke on the phone you offered that they were similar, but I think thats all I heard from that.

In your answer to Arcane, you speculated that tobacco was a killer. I'm not disagreeing with that per se, however, the Surgeon General's data on that matter from the 60s contradicts your point. Cigarettes are killers (increasing mortality rate), pipes aren't and cigars are in extremely high doses. Or am I misinterpreting the Surgeon General's results? Was there data that superceeded that 1960s Surgeon General Data or is that still considered accurate?

In that vein (), you offered the idea that Carbon Monoxide levels in the blood stream were 3x higher for the durations you defined. We're talking blood levels. The Surgeon General has said in several places that "whether you inhale or not" cigars still cause cancer. Presumably because the chemicals are absorbed into the bloodstream. I would imagine that the blood is relatively uniform and that the CO levels in all the blood in a particular person would show the same levels. There are two models that would seem to be reasonable here, but when we're talking about blood levels, wouldn't pipe, cigar and cigarette smokers have similar levels of pre-carcinogens, carbon monoxide, nicotine, etc. (Not identical, but similar). If the blood levels are similar, but the mortality rates are quite dissimilar, how could we logically explain that? Unless the blood levels are irrelevant, which would be the second model of this setup. If the blood levels are relevant, then why do pipe and cigar smokers get mouth and lip cancer while cigarette smokers get lung cancer? If the carbon monoxide is primarily evolved from combustion, then carbon monoxide would be absorbed into the blood stream through a number of routes, but it would be absorbed. The carbon monoxide in the bloodstream would lead to heart disease. If heart disease is a killer (which we know it is), it would figure into mortality rates. If those mortality rates for pipe smokers aren't elevated above non-smokers (Surgeon General's Report, 1964) and we are defining the carbon monoxide as universally a causative agent of heart disease, what is going on? Smoking a pipe, burning tobacco. Carbon monoxide comes from burning tobacco. Carbon monoxide causes heart disease. Heart disease cuts people's lives short, it increases mortality rate. Then, pipe smokers should show elevations in their mortality rate. They don't. Why?

I asked you that at a different point a similar question and you explained that the nature of cancers commonly associated with pipes and cigars were oral, more easily detected and treated, where the cancers associated with cigarettes were usually more severe and life threatening. You said this explained why the mortality rate for cigarette smokers was high while it was baseline for pipe smokers. On further reflection over the last few months, it doesn't explain where the mortality increases for Carbon Monoxide went for pipe and cigar smokers. They should be there. Shouldn't they?

The other possibility is that these blood levels aren't significant. The mortality rate increase in cigarettes is different for some other reason other than the obvious things in common that pipes and cigarettes have. Care to speculate?

Also, if we establish that most of the harm from a hookah comes from charcoal, couldn't we identify what elements in charcoal are the most hazardous and then make charcoal lacking or minimizing those elements? Is there some study or model that we could broach that idea with? Could we just test charcoal independent of the tobacco and find out what is being produced and use that to generalize the harmful effects smoking a hookah with that charcoal? I would imagine that based on the study regarding cigarette carcinogen production being positively correlated with ignition temperature that a cooler burning charcoal would produce less carcinogens, off the top of my head. Another thing I would be interested in is the link between sulfur and CO production. I feel, perhaps based only on my meager chemistry understanding, that CO production will be lower in charcoal with fewer unoxidized constituents, notably sulfur, a large additive in many types of charcoal, not only as a cheap accelerant, but as a constituent in binders to extrude charcoals in formed pieces.

[Bulldog_916]

Why is it that mean levels of CO in hookah are so low when compared to a condition that might cause real harm like a leaking natural gas stove or running the car in the garage for a minute or 2? You're talking about the intake of a fractional percentage of CO for a short period of time in the day or during the week, whatever the frequency of smoking is. It seems that the larger the hookah the lower the CO exposure is. And in that same breath, with adequate ventilation, the danger of carbon monoxide exposure in hookah is relatively low when compared other much more dangerous conditions. The danger really is based on how long the exposure is, how long after the exposure that the user is not exposed, and the quality/quantity of the exposure...correct?

[Sonthert]

I should also add, due to your 'discouraging' remarks about my week-long fast, I decided to smoke a hookah. The fast is over. I wasn't noticing any real changes in me or in my physiology/mental state. Your thoughts in the matter punctuated this point. I'm not going to quit for a lifetime.

[Sonthert]

Eddie, I think if Tom were on the interwebs, he would point out you are comparing chronic levels with gross acute toxicity levels. A smaller chronic exposure to a particular chemical may have severe repercussions moreso than the one-time large ingestion of a chemical.

[Sonthert]

In a related point, Tom, wouldn't the gross weight of tobacco burned by an average cigar or pipe smoker be in excess of the average cigarette smoker? That being the case, wouldn't more CO be produced, meaning a greater risk of heart disease for a cigar/pipe smoker than for a cigarette smoker? Wouldn't that increase the chances of dying from these significantly...increasing mortality rates?

[Sonthert]

[quote name='Teissenb' date='20 December 2009 - 11:35 AM' timestamp='1261334127' post='440572']
Looks like my links got blocked by VCU. Sorry. Let's try these:

PAHs: [url="http://www.ncbi.nlm.nih.gov/pubmed/18308445?itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVDocSum&ordinalpos=8"]http://www.ncbi.nlm....um&ordinalpos=8[/url]

Volatile aldehydes: [url="http://www.ncbi.nlm.nih.gov/pubmed/18834915?itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVDocSum&ordinalpos=5"]http://www.ncbi.nlm....um&ordinalpos=5[/url]
[/quote]

I can't get those links to work. They must know I'm a tobacco manufacturer!

[Bulldog_916]

But, in the OSHA standards there is a mean level of CO that you can be exposed to in a typical work day for however long you're there. That could be in excess of 8 hours. At exposure level of 50ppm, it seems that in the work place that is acceptable. How is that not CH low-level exposure and why arent people in the thousands that work in that condition every day dropping dead at 50 years old from CH exposure? How is that connection not being made? Wouldnt we want to fight CO exposure at higher levels in the work place and not at very low levels, non-chronically in hookah smokers? Because not all of us do it every day or even twice a week.

[Bulldog_916]

EDIT, sub CO for CH in this. I dont know what I was thinking.

[Bulldog_916]

Some interesting tidbits on OSHA and CO exposure.

[url="http://www.osha.gov/SLTC/healthguidelines/carbonmonoxide/recognition.html"]http://www.osha.gov/SLTC/healthguidelines/carbonmonoxide/recognition.html[/url]


"2. Effects on Humans: Carbon monoxide is an asphyxiant in humans. Inhalation of carbon monoxide causes tissue hypoxia by preventing the blood from carrying sufficient oxygen. Carbon monoxide combines reversibly with hemoglobin to form carboxyhemoglobin. The reduction in oxygen-carrying capacity of the blood is proportional to the amount of carboxyhemoglobin formed [Gosselin 1984]. All factors that speed respiration and circulation accelerate the rate of carboxyhemoglobin formation; thus exercise, increased temperature, high altitude, and anemia increase the hazard associated with carbon monoxide exposure[Gosselin 1984]. Other conditions that increase risk are hyperthyroidism, obesity, bronchitis, asthma, preexisting heart disease, and alcoholism [NLM 1993]. In tests with human volunteers breathing 50 ppm carbon monoxide (a concentration that produces 27 percent carboxyhemoglobin after an exposure of 2 hours), there was a significant decrease in time to onset of exercise-induced angina[Gosselin 1984]. Carbon monoxide can be transported across the placental barrier, and exposure in utero constitutes a special risk to the fetus. Infants and young children are generally believed to be more susceptible to carbon monoxide than adults. The elderly are also believed to be more susceptible to carbon monoxide poisoning [Gosselin A carboxyhemoglobin level of 0.4 to 0.7 percent is normally present in the blood of adults. In cigarette smokers, the range is 4 to 20 percent, which places smokers at greater risk in exposure situations [Clayton and Clayton 1982; ACGIH 1991]. A capacity to adapt to carbon monoxide exposure has been reported in several human studies. Healthy young men exposed to carbon monoxide at a concentration of 44 ppm for a prolonged period suffered no adverse health effects [ACGIH 1986]. Men exposed to 50 ppm for several days without relief complained of headaches, but exposure to 40 ppm for 60 days was without effect [ACGIH 1986]. Workers in the Holland Tunnel working 8-hour swing shifts of 2 hours in and 2 hours out at an average carbon monoxide exposure concentration of 70 ppm had average carboxyhemoglobin levels of 5 percent, and none had levels above 10 percent [ACGIH 1991]."

[Teissenb]

The CO levels are lower than if you ran your car in your garage for 20 minutes because the exposure is less. Look, I am not saying that cigarette smokers or hookah smokers die from acute CO poisoning, as might happen to someone who ran their car in an airtight garage. That assertion would be absurd on its face. The health effects of long-term, low-level exposure to CO are much more insidious, and are thought to underlie the pronounced risk of cardiovascular disease seen in cigarette smokers. In the hookah context, there are at least three reasons why the CO exposure data are important:

1) They dispel the myth that hookah smokers do not inhale smoke toxicants (i.e., the water filters the bad stuff out). It doesn't. Hookah smokers inhale CO and nicotine, these toxicants are in their blood, and the nicotine is physiologically active (i.e., it raises heart rate). We know that there are PAHs and volatile aldehydes in hookah smoke that has passed through water and there is every reason to believe that hookah smokers are also exposed to these toxicants.

2) They dispel the myth that hookah smoking is somehow associated with less toxicant exposure than cigarette smoking. Comparing 5 minutes of hookah smoking to 5 minutes of cigarette smoking, hookah smokers have been exposed to MORE CO than cigarette smokers and the nicotine exposure does not differ. At 45 minutes (a typical session, we have seen and are told), hookah smokers are exposed to 3 times as much CO. We know that PAH yield in hookah smoke can be 20-200 times that in cigarette smoke (depending in the particular PAH being looked at) so, again, there is every reason to believe that a single hookah session can lead to more carcinogen exposure than one cigarette, perhaps many times more.

3) They suggest that, just as cigarette smokers die from cardiovascular disease that is caused by long-term, low level CO exposure, hookah smokers may also be at risk for death from cardiovascular disease.

FYI, our study took place in a well-ventilated room with a MYA hookah. Hookah smokers are INHALING the CO, so the level of ventilation is not the main issue (though, yes, I suspect if you smoked in an unventilated space, and/or with many other hookahs around, your CO exposure would be even greater).

Certainly, I agree that the danger is related to how long-term the exposure is. If everyone here quit smoking tobacco now, there is every reason to believe that they will be spared tobacco-induced addiction, disease, disability, and death.




[quote name='Bulldog_916' date='22 December 2009 - 05:27 PM' timestamp='1261528075' post='441069']
Why is it that mean levels of CO in hookah are so low when compared to a condition that might cause real harm like a leaking natural gas stove or running the car in the garage for a minute or 2? You're talking about the intake of a fractional percentage of CO for a short period of time in the day or during the week, whatever the frequency of smoking is. It seems that the larger the hookah the lower the CO exposure is. And in that same breath, with adequate ventilation, the danger of carbon monoxide exposure in hookah is relatively low when compared other much more dangerous conditions. The danger really is based on how long the exposure is, how long after the exposure that the user is not exposed, and the quality/quantity of the exposure...correct?
[/quote]

[Teissenb]

Eric,

You keep trying to puzzle out some flaw in the study. Of course it has limitations, but the overall message, which I will not reiterate in detail here again, is clear: hookah smokers are exposed to the toxicants CO and nicotine. Even after 5 minutes, the CO exposure is greater than a cigarette and the nicotine level does not differ. You can quibble about this detail or that detail, but you are not going to change these observations.

If you look at the plasma nicotine figure in the Eissenberg and Shihadeh (2009) paper, you will see data that supports your position that more nicotine is delivered at the beginning of the hookah session than at the end. From the CO figure you will see that the CO increases are fairly constant throughout the session. So if you are arguing that hookah smokers should decrease their smoking from 45 minutes (on average) to 5 minutes (so as to maximize nicotine and minimize CO exposure), I agree that such a decrease would be a nice first step toward total cessation.

I have not seen an analysis of the glycerine content of hookah smoke. What I have seen, and what I've sent to you now, are high quality scientific papers that clearly indicate that hookah smoke contains carcinogenic PAHs (in the "tar") and lung-disease causing volatile aldehydes (in the gas phase). I have always maintained that the "tar" content of hookah smoke is likely to differ from that of cigarette smoke in some ways. Because we ALL believe that, Dr. Shihadeh has been investigating, and continues to investigate, what compounds specifically are in the smoke. Your point that the gross "tar" weight may be influenced by glycerine is well-taken. My point that the tar contains substantial amounts of carcinogenic PAHs is not altered by yours and, I would think, would be the more relevant to hookah smokers' health (though long-term inhalation of glycerine may also be damaging to the lung). And, as an aside, I can ASSURE you that his waterpipe preparation includes perforated foil covering the tobacco; he DOES NOT put the charcoal directly on the tobacco.

I must caution you strongly about basing an argument in 2009 on data presented in a 1963 Surgeon General's report. We can all learn a lot in 46 years.

I make no claim to being an expert on all aspects of tobacco, and happily acknowledge that any information I could give you regarding death rates and causes of death in cigar and pipe smokers would come from the same sort of internet searches that you might do (I would weight wikipedia low and pubmed high on my source list ). I see from a quick search that a 2003 paper (Shaper et al., 2003; [size="-1"][i]International Journal of Epidemiology[/i];[b]32[/b]:802-808[/size]) reports the following results (note that CHD = coronary heart disease):

Compared with never smokers, pipe/cigar smokers (primary and[sup] [/sup]secondary combined) showed significantly higher risk of major[sup] [/sup]CHD events (relative risk [RR] = 1.69, 95% CI: 1.32, 2.14) and[sup] [/sup]stroke events (RR = 1.62, 95% CI: 1.08, 2.41) and of cardiovascular,[sup] [/sup]non-cardiovascular, and total mortality (RR = 1.49, 95% CI:[sup] [/sup]1.13, 1.96, RR = 1.40, 95% CI: 1.08, 1.83 and RR = 1.44, 95%[sup] [/sup]CI: 1.19, 1.74, respectively), after adjustment for lifestyle[sup] [/sup]and biological characteristics. They also showed a significantly[sup] [/sup]higher incidence of smoking-related cancers (RR = 2.67, 95%[sup] [/sup]CI: 1.70, 4.26), largely due to lung cancer (RR = 4.35, 95%[sup] [/sup]CI: 2.05, 8.94). Overall, the effects in pipe/cigar smokers[sup] [/sup]were intermediate between never-smokers and light cigarette[sup] [/sup]smokers, although risks for lung cancer were similar to light[sup] [/sup]cigarette smokers.

So, I am reading these data to say that pipe/cigar smokers ARE at increased risk for cardiovascular disease and at least some cancers relative to a non-smoking population, but that the level of increased risk is less than that of pack/day cigarette smokers. Again, this area is not my expertise and, of course, this study is only one of many addressing these points.

Having now scanned the article itself (link below), I read:

The American Cancer Society (1998) concluded that (1) smoking[sup] [/sup]cigars instead of cigarettes does not reduce the risk of nicotine[sup] [/sup]addiction, (2) cigar smoke contained higher concentrations of[sup] [/sup]toxic and carcinogenic compounds than cigarettes and was a major[sup] [/sup]source of carbon monoxide, (3) cigar smoking causes cancers[sup] [/sup]of the oral cavity, larynx, lung, and oesophagus, and (4) with[sup] [/sup]increasing numbers of cigars smoked, the risk of death approached[sup] [/sup]that of cigarette smoking.[url="http://ije.oxfordjournals.org/cgi/content/full/32/5/802#R31"][sup]31[/sup][/url] The findings in the present study[sup] [/sup]in middle-aged men who are pipe and/or cigar smokers supports[sup] [/sup]these conclusions and suggests that ‘cessation of all[sup] [/sup]tobacco products is the best strategy for decreasing exposure[sup] [/sup]to tobacco smoke’.[url="http://ije.oxfordjournals.org/cgi/content/full/32/5/802#R32"][sup]32[/sup][/url]

Please take a look:

http://ije.oxfordjournals.org/cgi/content/full/32/5/802

For what its worth, a 1981 study (Wald et al) reported that "Using a COHb cut-off level of 2%, 81% of cigarette smokers, 35% of cigar and pipe smokers, and 1.0% of non-smokers had raised COHb levels." These data suggest to me that cigare smokers are exposed to less CO than cigarette smokers but more CO than nonsmokers, which could account for the intermediate levels of cardiovascular disease in cigar smokers in the Shaper et al 2003 study.

I think the data are clear, Eric: tobacco smoking is bad for people's health. Smoking tobacco is bad for people's health because the smoke contains CO, and carcinogens, and volatile aldehydes and all sorts of other stuff that the human lung has not evolved to deal with. Smoking tobacco is bad for people's health whether they are using a cigarette or a cigar, or a pipe. Based solely on the data I have reviewed on this thread, smoking tobacco is also bad for people's health if they are using a waterpipe (hookah, shisha, narghile).

Tom E.

[Tikhman]

Tom, your study is actually one of the better designed ones I've seen and I'm curious why you haven't put smoke samples through a GC/MS. It would have been very simple to place the absorbent fiber for the GC in place of your flow censors. While there is merit to measuring CO and nicotine blood levels, there are multiple other compounds in cigarettes that are known to be carcinogenic/related to other problems. I saw the 2 lines addressing this in your conclusions, but you did not show any data on anything other than CO and nicotine.

I've given thought to hijacking our GC/MS but unfortunately its being extensively used at the moment and bringing a hookah into lab is also a bit questionable. Maybe somewhere down the road [img]http://www.hookahforum.com/public/style_emoticons/default/_sheesha2__by_Majunka_aurore.gif[/img]

Ilya

[shaffaaf27]

[quote name='Sonthert' date='23 December 2009 - 01:15 AM' timestamp='1261530943' post='441097']
I should also add, due to your 'discouraging' remarks about my week-long fast, I decided to smoke a hookah. The fast is over. I wasn't noticing any real changes in me or in my physiology/mental state. Your thoughts in the matter punctuated this point. I'm not going to quit for a lifetime.
[/quote]

FAIL:lol_hitting:

thats my contribution