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  1. Publication Bias, Misrepresentations and Serious Errors in Study on Canadian and English students' Beliefs about "Waterpipe" Smoking

    Kamal Chaouachi, Tobacco researcher and consultant, DIU Tabacologie, Universite Paris XI

    4 February 2009


    I am the author of early comprehensive transdisciplinary qualitative studies which have led, in particular, to identifying the reasons for which people have been smoking hookah (narghile, shisha) for centuries and are now indulging in it with renewed interest [**]. This has been made possible thanks to the transdisciplinary (social and biomedical sciences) framework set for these studies from the outset. As expected, this work, but also other relevant references by other authors, was completely dismissed in ROSKIN and AVEYARD's paper [1]. The motives behind such a publication bias are to be found in the "prohibitionist agenda" (sic) put in place by the anti-smoking organisations [2]. Indeed, in such a context, a recent scholar who has fought tobacco diseases for most of his life and who is also the founder of tobacco science (understood as a scientific discipline taught in universities to medical doctors), was recently amazed to see how an erroneous and biased supranational expert report behind the very smoking bans in Europe had remained uncommented. He literally asked: "Epidemiological Study or Manipulation ?"[3].

    Noteworthy, in ROSKIN and AVEYARD's paper, is the fact that 11 studies, out of the 13 ones cited and having a direct connection with the issue at stake, are form the US-Syrian Centre for Tobacco Studies. Strikingly, they all use the ""waterpipe"" (in one word) neologism which has proved to be not only a scientific nominalism but also what I named a sociological code [4]. To close this chapter, let me emphasise that this criticism also applies to a previous manuscript by the same authors [5].


    ROSKIN and AVEYARD said their aim was "to understand the appeal to students of this form of smoking". However, one of the main reasons behind the revival of hookah smoking in the world is in fact a new kind of charcoal, formerly used to burn incense. Another one is the backlash effect of international campaigns against cigarette smoking [6][7]. I note that none of both key points were treated as such.

    Hookah smoking is not only "becoming popular among western students" (abstract) but among all social and cultural categories and across the world: northward, southward, eastward and westward [6]. Furthermore, the authors point out that hookah smoking is "a traditional form of tobacco smoking in the Middle East" and support this statement with a publication which actually offered an erroneous scenario of the hookah epidemic [6][8].

    In their conclusion, the authors see that because of "the absence of public health information, students have fallen back on superficial experiences to form views that waterpipe smoking is less harmful than other forms of smoking and it is currently much more acceptable in student society than other forms of smoking". Amazingly, and in sharp contrast, a heavy international public health information campaign was led against hookah smoking. Indeed, within a few years, more than a half hundred of """waterpipe""" specific studies were conducted and widely advertised [9].

    ROSKIN and AVEYARD quote from a student having "a background in scientific education [whose] beliefs were based upon the opinion of a toxicology teacher" that "in shisha... the way it's prepared with sugar in tobacco and charcoal, glycerine burns in the head producing free radicals. These are very harmful and causing cancers"".

    In fact, the interviewed student is not less ignorant (regarding health effects) that the others described as unaware of the corresponding risks. Indeed, as recalled several times in the literature not cited by the authors, the hookah smoking mixture is not subjected to a burning process but is simply heated [6][7][10]. As for glycerol, no cracking that could potentially produce (water soluble) acrolein is expected as far as temperatures are kept within normal conditions of use. As far as free radicals are concerned, the only specific study identified so far, and not cited by ROSKIN and AVERYARD, showed that the water in the hookah acts as an antioxydant against some short half-life free radicals [10]. Fortunately, the first aetiological study on hookah smoking and cancer among exclusive users has cleared up a great deal of the international confusion [10].

    The authors wished to draw the attention of their interviewees on the "misleading" figures printed on the moassel (the hookah smoking mixture) packs: namely "0% tar, 0.5% nicotine". The authors speculate that the latter are supposed to induce and reflect the ignorance of hookah users. In fact, these figures are not less unrealistic than those advertised in ""waterpipe"" studies [6].

    Generally speaking, what is not understood by world ""waterpipe"" experts in general and the two authors in particular is that hookah smoke is actually far less complex than cigarette smoke. For the first time in 1991, 142 compounds were detected in its smoke with a filtration rate of 38%. This figure is to be compared to the 4700 substances that have been identified so far in cigarette smoke [9].

    The authors follow: "Epidemiological studies show evidence that waterpipe smoking is associated with an increased risk of cardiovascular disease and cancer and with proxy markers of the risk of developing these". On one hand, the two references cited to support this statement are controversial studies containing numerous errors [11][12]. Particularly, the one by MAZIAK et al is once again blindly cited to support the statement that narghile smoking would cause lung cancer, i.e. the opposite finding reached by the researchers cited by MAZIAK et al, namely RAKOWER and FATAL [10][13].

    On the other hand, a recent study from Jordan involving a wide sample (14,310 subjects) shows modest increases of the relevant parameters when compared with cigarette smokers. The rise of arterial blood pressure in "pure"/exclusive shisha smokers varied from 92.57 ±13.90 to 92.62±10.58. The heart rate changed from 76.40±10.46 to 76.81±10.19 [14]. Another controversial publication cited by ROSKIN and AVEYARD is the "COCHRANE review of interventions to encourage waterpipe smokers to stop"[15]. This publication by MAZIAK et al has been criticised for its publication bias whereby, in particular, an important 84 page WHO report on shisha smoking was dismissed in the related review of the literature [16]. It also contains serious errors criticised in the study on hookah smoking and cancer and in another one on the radiological hazards of hookah smoking [10][17].

    In the paragraph about harm reduction options such as the efficient smokeless tobacco of the Swedish SNUS type, ROSKIN and AVEYARD state that "Waterpipe smoking involves burnt tobacco, and is therefore likely to be considerably more harmful than snus". The first error is that the smoking mixture is not burnt. The second one is that no study has compared so far hookah smoking and SNUS. However and interestingly, the first study on hookah and cancer has invited public health authorities and actors around the world to consider the use of this smokeless tobacco product for heavy hookah users only [10].

    The authors conclude that "the current lack of health information is currently viewed as tacit official acceptance of waterpipe smoking". The misrepresentation here is that that users have seen by themselves how public health interventions have lost their credibility because of repeated publication bias and fatal errors in studies supposed to be of a high-standard. For instance, They often object to any interviewer the fact that there has been a tremendous confusion between the chemistry of burned tobacco and that of a heated tobacco-molasses based mixture.

    Dr Kamal Chaouachi (
    Tobacco researcher and consultant, DIU Tabacologie, Universite Paris XI. Author of early qualitative studies on this issue.

    COMPETING INTERESTS: I have unfortunately no competing interests. I have never received direct or indirect funding neither from pharmaceutical companies (nicotine ''replacement'' therapies and products) nor from the tobacco industry. Yet, I would consider with interest any financial or logistic support from any of both.



    [1] Roskin J, Aveyard P. Canadian and English students' beliefs about waterpipe smoking: a qualitative study. BMC Public Health. 2009 Jan 10;9(1):10.

    [2] Chaouachi K. Rebuttals to Maziak. Harm Reduction Journal 2008 (16 Jun - 12 July):

    [3] Molimard R. [The European Report "Lifting the SmokeScreen": Epidemiological study or manipulation?] Rev Epidemiol Sante Publique. 2008 Aug;56(4):286-90. [incl. English translation]

    [4] Chaouachi K. To whom does 'public health' belong when it comes to 'Waterpipe' Smoking ? Australian and New Zealand Journal of Public Health 2008; 32 (6): 583.

    [5] Jackson D, Aveyard P. Waterpipe smoking in students: prevalence, risk factors, symptoms of addiction, and smoke intake. Evidence from one British university. BMC Public Health. 2008 May 22;8(1):174.

    [6] Chaouachi K. A Critique of the WHO's TobReg "Advisory Note" entitled: "Waterpipe Tobacco Smoking: Health Effects, Research Needs and Recommended Actions by Regulators. Journal of Negative Results in Biomedicine 2006 (17 Nov); 5:17.

    [7] Chaouachi K. The Medical Consequences of Narghile (Hookah, Shisha) Use in the World. Revue d'Epidemiologie et de Sante Publique (Epidemiology and Public Health) 2007a;55(3):165-70 [in English].

    [8] Chaouachi K. Errors in the Scenario for the Narghile Epidemic in Syria. A critical analysis of: "Rastam S, Ward KD, Eissenberg T, Maziak W: Estimating the beginning of the waterpipe epidemic in Syria. BMC Public Health 2004, 4:32.". BMC Public Health 2007 (30 Dec).

    [9] Chaouachi K. To whom does 'public health' belong when it comes to 'Waterpipe' Smoking ? Australian and New Zealand Journal of Public Health 2008; 32 (6): 583.

    [10] Sajid KM, Chaouachi K, Mahmood R. Hookah smoking and cancer. Carcinoembryonic Antigen (CEA) levels in exclusive/ever hookah smokers. Harm Reduction Journal 2008 24 May;5(19)

    [11] Knishkowy B, Amitai Y: Water-Pipe (Narghile) Smoking: An Emerging Health Risk Behavior. Pediatrics 2005, 116: e113-e119.

    [12] Maziak W, Ward KD, Afifi Soweid RA, Eissenberg T: Tobacco smoking using a waterpipe: a re-emerging strain in a global epidemic. Tob Control 2004, 13: 327-333.

    [13] Rakower J, Fatal B. Study of Narghile Smoking in Relation to Cancer of the Lung. Br J Cancer 1962; 16:1-6.

    [14] Al-Safi SA, Ayoub NM, Albalas MA, Al-Doghim I, Aboul-Enein FH (2008) Does shisha smoking affect blood pressure and heart rate ? J Public Health [Online First, 15 Nov 2008]

    [15] Maziak W, Ward K, Eissenberg T. Interventions for waterpipe smoking cessation. Cochrane Database Syst Rev. 2007 Oct 17;(4):CD005549.

    [16] WHO-EMRO (World Health Organisation - Eastern Mediterranean Regional Office) and ESPRI (Egyptian Smoking Prevention Research Institute)(2007). Shisha Hazards Profile "Tobacco Use in Shisha - Studies on Water-pipe Smoking in Egypt". Cairo (14 March). ISBN: 978-92-9021-569-1. 84 pages. Prepared by Senior editors: Mostafa K. Mohamed, Christopher A. Loffredo, Ebenezer Israel et al.

    [17] Khater AE, Abd El-Aziz NS, Al-Sewaidan HA, Chaouachi K. Radiological hazards of Narghile (hookah, shisha, goza) smoking: activity concentrations and dose assessment. J Environ Radioact. 2008 Dec;99(12):1808-14.

    Competing interests

    I have unfortunately no competing interests. I have never received direct or indirect funding neither from pharmaceutical companies (nicotine 'replacement' therapies and products) nor from the tobacco industry. Yet, I would consider with interest any financial or logistic support from any of both.