Something Falsely Reported. False Information

[Teissenb]

Ilya:

Thanks for the comments. Dr. Alan Shihadeh has done exactly as you propose in a series of excellent studies starting with Shihadeh 2003, then Shihadeh & Saleh, 2005, then several more that I have linked to in this thread. If you go to Pubmed and search for "Shihadeh" you'll find them easily.

Tom E.


[quote name='Tikhman' date='23 December 2009 - 04:06 PM' timestamp='1261609579' post='441355']
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
[/quote]

[Tikhman]

Ha, thats what I get for being lazy and not checking pubmed to begin with.

Here's are a couple of other questions.

So the studies showed that majority of PAHs come from the coal and you happen to be using the quick light coals that have added chemicals to help with quick combustion. Do you know of plan to look at various kinds of coals, lets say lemonwood, orangewood, coconut and quicklights. I'd be interested to see if those numbers come from the actual coal or if some of that is the effect chemicals added for combustion.

A minor comment, from one of their diagrams is looks like they leave a good amount of empty space when they pack tobacco in the bowl (between tobacco and foil), something that is not a common practice, at least not with that brand of tobacco.

[Teissenb]

I agree that the study you suggest is potentially interesting. These studies are also quite expensive and we have other issues that we are pursuing at the moment. I can tell you that, as far as CO goes, we have done some studies with people smoking when using "traditional" charcoal in Syria and the CO exposure is virtually identical with that observed when people are using "quick light" charcoal. However, this does not address your PAH question, I admit.

I cannot comment on the bowl packing in Shihadeh's preparation as I have not observed him or his staff pack a bowl. When I pack the bowls in my laboratory there is not much space, if any, between tobacco and foil. More importantly, many of the folks in our study report that they enjoy the bowl and that it was packed well. We also have offered folks the opportunity to pack their own bowls and hope at some point to have enough of these people to compare exposure in "self-packers" with that of "staff packed" bowls -- but I sincerely doubt this variable influences the results.

Tom E.



[quote name='Tikhman' date='24 December 2009 - 08:56 AM' timestamp='1261670188' post='441479']
Ha, thats what I get for being lazy and not checking pubmed to begin with.

Here's are a couple of other questions.

So the studies showed that majority of PAHs come from the coal and you happen to be using the quick light coals that have added chemicals to help with quick combustion. Do you know of plan to look at various kinds of coals, lets say lemonwood, orangewood, coconut and quicklights. I'd be interested to see if those numbers come from the actual coal or if some of that is the effect chemicals added for combustion.

A minor comment, from one of their diagrams is looks like they leave a good amount of empty space when they pack tobacco in the bowl (between tobacco and foil), something that is not a common practice, at least not with that brand of tobacco.
[/quote]

[Sonthert]

[quote name='Teissenb' date='23 December 2009 - 05:08 AM' timestamp='1261570110' post='441248']
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.
[/quote]

Again, Tom, understand, if I can make a contribution to reducing the risk associated with smoking a hookah, I need to get my fingers in firmly on the problem. If I spend 6 months working on a faulty premise, I could find a solution that is not helpful, or even worse, more damaging. If ask a lot of what seem like stupid or challenging questions, its only to satisfy variables in my mind. For instance, one concept I have felt out with you is:

The risks from smoking cigarettes is higher than for smoking a hookah. Why? If the answer is "Principally because cigarettes have X, Y and Z added where Tangiers hookah tobacco doesn't have those same additives." My work is done, nothing needs to be done. If its because tobacco is burning, and hookah tobacco is actually burning, despite what seems to be the case, this is the opposite, but the same case, nothing is to be done, except use lower-nitrosamine tobacco and whatnot. If the risk is principally from the charcoal, is it due to the combustion of the carbon or from additives to the carbon? If its principally from the combustion of the carbon, nothing more can be done except switch to some form of non-combusting heat source. If its from the additives to the charcoal, address that. Etc. If you see where my mind is going here.

In terms of the 1963/1964 Surgeon General's Report, again, if that report has validity, why does it differ from other data and in what ways? If it doesn't (In either case), why not? How could the Surgeon General publish information that is wrong and why was it wrong? If its right, doesn't that cast a different light on my efforts than if its wrong? Of course it does. For instance, if the mortality rates are nearly identical between a pipe smoker and a non-smoker, the diseases caused by smoking a pipe have to be extremely non-prevalent or non-life threatening. I could read a whole bunch of studies, some conflicting with each other,

Of course, on the crude face of it, if my chances of dying from smoking a pipe are the same as not...why worry? Your increased mortality statistics you quoted adds a "how much" risk factor to it, not a "Why worry?". Its not like I'm sitting here waiting for some tremendous "Ah Ha! I've got you now." I'm not a big fan of epidemiological numbers, I feel that incorrect assumptions might lead to incorrect risk assessment, one way or the other. Just because I'm a skeptical or an exigent person doesn't mean I'm trying to disprove what your saying. You seem suspicious of my motives. If your suspicions are well founded (Which they aren't), then the only thing that could be worrisome is that there were flaws in the science. I don't think thats the case, but I'm still personally skeptical. I expect when I die, I'll keep moving around for a couple of months because I'll be skeptical of the people saying I'm dead.

What are good numbers for the CI and RR of cigarette smokers? They were mentioned in the paper, as "light" or "intermediate" cigarette smoking, what numbers are those associated with? This is also very good because I'm rebulking on statistics I forgot a long time ago.

So, in short, in that study, we're taking the number of deaths for group X (smokers), dividing by the deaths for the control group (or non-smokers in this case) (assuming we're looking at the same study sizes) and arriving at the RR. Isn't this roughly the same case as the question I posed by PM, where some sources say that a 100% increase (Odds ratio?) in deaths, disease or whatever constitute the threshold between correlative and causative? That is, if the statistics for lung cancer from Second-hand smoking is 10 out of 100000 for non-smokers and 13 out of 100000 for second-hand smokers, Whereas the ratio for lung cancer in [i]primary[/i] smokers is 35 (or is it?)...or 350 cigarette smokers for every 10 non-smokers get lung cancer (out of 100,000). So isn't 1.3, 1.4 or 1.6 relatively low ratios in relation to the ratios seen in primary smokers?

And for those of you reading my responses, despite any skeptical retorts, please note: You are killing yourself by smoking. You are shortening your wonderful life. Its a very stupid thing to do. You increase your risk of getting any number of horrible ways of dying in the deal, which will leave you the alternative of dying in a prolonged misery or jumping off of a bridge.

[Teissenb]

Eric:

With regard to the 1963/4 SG's report, that report represented the best knowledge available at that time. It was valid at the time it was printed. Since then, MANY new studies have been conducted with larger samples, better methods, etc. etc. These new studies render that report an interesting historical document that is not valid in our time. Science often works this way: conclusions reached based on data from some period ago are supplanted by new conclusions based on new/better data. For example, the prevailing thought in the early 1800s was that cholera was spread through the air (especially very smelly air). Thanks to the pioneering work of the brilliant "father of epidemiology" Dr. John Snow, we learned in the mid-1800s that cholera was spread by germs contained (often) in contaminated water/food (he didn't actually tell us about the germs, he told us about the means by which they were spread). If there were SGs reports written about Cholera in 1840 and 1890, they would each have come to very different conclusions about how to avoid/stop cholera epidemics. The earlier one would have been a sincere attempt at preserving public health that was based on the best available evidence and it would have been valid for its time. The later one would have been equally sincere, also based on the best available evidence, and also valid for its time. Looking at the two today, we would CLEARLY see that the earlier report was flat out wrong, and its recommendations useless for preserving the public health. We would also see that the later report was essentially correct and its recommendations hold true today. So it goes: as we learn more, we write new reports based on new data. We hope that, with each new report, there is a corresponding increasing in the health of the public and that, at some point, we can feel that we have the threat completely contained (as with smallpox, for instance).

I cannot address your statistical questions in detail. I agree that, based on the one study to which I linked us, the risk of dying of tobacco-caused disease is lowest in non tobacco users, higher in pipe/cigar smokers, and highest in cigarette smokers. With regard to smoking-caused cardiovascular disease, one possible explanation for this ordering of risk (cigarette > cigar/pipe > nonsmokers) might be related to the fact that CO exposure follows the same pattern (e.g., Wald et al., 1981).

I may be wrong, but I think that you are saying that, for you, the risks of dying of tobacco-caused disease from years of cigarette smoking are so great that you won't engage in that behavior, but you feel that the risks of dying from tobacco-caused disease from years of hookah smoking (or cigar, or pipe) are not so great (though you recognize that they are greater than not smoking anything), and so you will engage in this behavior. Given no one has yet quantified the risk of hookah smoking, I cannot fault you for this logic. Imagine a scale measuring "risk of dying from tobacco-caused disease" and that not smoking puts you at a 1 and smoking 2 packs of cigarettes each day puts you at 100 (you recognize that I am making up this scale, I'm sure). If hookah smoking puts you at a 2, then you might feel better about your decision than if hookah smoking puts you at a 50. What I think a lot of people on this board and elsewhere fail to realize is that finding the right number for hookah is what my colleagues and I are trying to do as precisely, accurately and quickly as possible (this includes the folks at the World Health Organization). We want YOU to be informed so that when you make this decision, you are making it using accurate information. Many hookah smokers have told me that they don't smoke cigarettes because they know how dangerous they are. OK. What if smoking a hookah were equally or more dangerous? What if it were only slightly less dangerous? What if it were much less dangerous? We are trying to answer these questions the best way we know how. Edited December 26, 2009 by Teissenb

[Bulldog_916]

[quote name='Teissenb' date='26 December 2009 - 09:22 AM' timestamp='1261848129' post='441854']
Eric:

With regard to the 1963/4 SG's report, that report represented the best knowledge available at that time. It was valid at the time it was printed. Since then, MANY new studies have been conducted with larger samples, better methods, etc. etc. These new studies render that report an interesting historical document that is not valid in our time. Science often works this way: conclusions reached based on data from some period ago are supplanted by new conclusions based on new/better data. For example, the prevailing thought in the early 1800s was that cholera was spread through the air (especially very smelly air). Thanks to the pioneering work of the brilliant "father of epidemiology" Dr. John Snow, we learned in the mid-1800s that cholera was spread by germs contained (often) in contaminated water/food (he didn't actually tell us about the germs, he told us about the means by which they were spread). If there were SGs reports written about Cholera in 1840 and 1890, they would each have come to very different conclusions about how to avoid/stop cholera epidemics. The earlier one would have been a sincere attempt at preserving public health that was based on the best available evidence and it would have been valid for its time. The later one would have been equally sincere, also based on the best available evidence, and also valid for its time. Looking at the two today, we would CLEARLY see that the earlier report was flat out wrong, and its recommendations useless for preserving the public health. We would also see that the later report was essentially correct and its recommendations hold true today. So it goes: as we learn more, we write new reports based on new data. We hope that, with each new report, there is a corresponding increasing in the health of the public and that, at some point, we can feel that we have the threat completely contained (as with smallpox, for instance).

I cannot address your statistical questions in detail. I agree that, based on the one study to which I linked us, the risk of dying of tobacco-caused disease is lowest in non tobacco users, higher in pipe/cigar smokers, and highest in cigarette smokers. With regard to smoking-caused cardiovascular disease, one possible explanation for this ordering of risk (cigarette > cigar/pipe > nonsmokers) might be related to the fact that CO exposure follows the same pattern (e.g., Wald et al., 1981).

I may be wrong, but I think that you are saying that, for you, the risks of dying of tobacco-caused disease from years of cigarette smoking are so great that you won't engage in that behavior, but you feel that the risks of dying from tobacco-caused disease from years of hookah smoking (or cigar, or pipe) are not so great (though you recognize that they are greater than not smoking anything), and so you will engage in this behavior. Given no one has yet quantified the risk of hookah smoking, I cannot fault you for this logic. Imagine a scale measuring "risk of dying from tobacco-caused disease" and that not smoking puts you at a 1 and smoking 2 packs of cigarettes each day puts you at 100 (you recognize that I am making up this scale, I'm sure). If hookah smoking puts you at a 2, then you might feel better about your decision than if hookah smoking puts you at a 50. What I think a lot of people on this board and elsewhere fail to realize is that finding the right number for hookah is what my colleagues and I are trying to do as precisely, accurately and quickly as possible (this includes the folks at the World Health Organization). We want YOU to be informed so that when you make this decision, you are making it using accurate information. Many hookah smokers have told me that they don't smoke cigarettes because they know how dangerous they are. OK. What if smoking a hookah were equally or more dangerous? What if it were only slightly less dangerous? What if it were much less dangerous? We are trying to answer these questions the best way we know how.
[/quote]

Even if you did quantify the risk to be more or close to the risk associated with cigarettes, I dont think people would really believe it. I mean, we know it isnt healthy. But at the same time, that "deadliness factor" is lost because of the pleasantness of the activity. The flavor and the smell doesnt turn people off to it like cigarettes. Is that to say you need to ban it because it is pleasant and it does turn people onto the activity? No. But even if you informed people of the danger, it just doesnt come off as being dangerous. It comes off as innocuous. Dont make it unpleasant in order to make people not do it. That's the wrong way to go. Inform yes. Dont act forcefully down to us on the information as the WHO has the tendency to do.