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Open Access Research article

Survey instruments used in clinical and epidemiological research on waterpipe tobacco smoking: a systematic review

Elie A Akl*, Sohaib Aleem, Sameer K Gunukula, Roland Honeine, Philippe Abou Jaoude and Jihad Irani

BMC Public Health 2010, 10:415  doi:10.1186/1471-2458-10-415

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“Systematic Reviews” on ““Waterpipe”” (Shisha, Hookah, Narghile) Tobacco Smoking Should Not Recycle Old Errors

Kamal Chaouachi   (2010-08-13 16:14)  Fellow Member of Alter-Tabacologie, France. email

Akl and colleagues' paper is one of a series of “systematic reviews” (on « health outcomes », « survey instruments » and, most recently, « lung function ») that pose serious problems [1][2][3].

The main ones are related to their publication bias and the indistinctive use, by the authors, of a neologism (“”waterpipe””)(in one word, this is very important) that has proved to be a spurious nominalism which has caused an international confusion never reached in the other fields of biomedical research [4].

Citing their previous « systematic review » on the subject [2], Akl et al do hype the association of hookah smoking with a certain number of cancers. However, the authors managed in that paper to select only the studies they saw relevant for their “assessment” of “health outcomes”, cancer in particular.

Amazingly, but not surprisingly on behalf of antismoking researchers (for whom “the epidemic of waterpipe smoking” need to be addressed «aggressively» [3]), and without giving any reason other than the scope of their “eligibility criteria”, they dismissed the most original and popular studies on hookah smoking and cancer (which highlighted -among other merits- a dose-response relationship)[5].

Certainly the « negative » findings of these studies are not in tune with the agenda of the world tobacco prohibition (cf: FCTC [Framework Convention for Tobacco Control], Globalink, in particular). Paradoxically, the authors mostly relied on studies led in China about local water pipes [2].

However, they did not realise that these pipes work with no charcoal and that tiny amounts of tobacco are burnt in them unlike the modern fashionable shisha which has got all antismoking organisations of the world concerned.

This modern form of water pipe (in two words, this is very important) works with a mixture of tobacco and molasses and –this is a very important detail- pieces of charcoal. In other words, tobacco is burnt in the Chinese pipes (as in cigarettes) while it is only heated in the fashionable shisha (unlike cigarettes).

This difference has tremendous consequences. As highlighted in critical publications, the chemistry of smoke is, in each case, completely different and, as a result, the potential health effects are expected to be very different [4][6][7].

As another methodological consequence, drawing “systematic reviews” of studies on «« waterpipe »» smoking, without realising that such studies are, most of the time, led on non uniform pipes, smoking products and quantities of the latter, amounts to comparing oranges with apples [4]. As in the case of Chinese studies, the pipes have nothing to do with what North-American teenagers do smoke today, supposing the authors' concern stands here since hookahs have been in use for centuries in Asia and Africa.

If the millions of individuals on these two continents have not realised over this span of time, then an explanation must be sought and this the first issue to be addressed. The same methodological mistake –of comparing incomparable objects- was made in Neergaard et al' “meta-analysis” in which the pooled studies, among other biases, involved different products for a direct comparison of nicotine levels [8].

As for the risk of bladder cancer, which Akl et al puts forward again, a recent article has identified the source of the world confusion [9].

Most recently, the same publication bias has led the same team not even mention the existence of Ben Saad et al's peer-reviewed publications on hookah smoking and the lung function [3][10]. We believe that, at least, some explanation should have been offered to the reader.

This series of « systematic reviews » relies itself on a series of antismoking publications labelled as « « waterpipe » » which, for most of them, have proved to be biased and containing numerous erroneous [4]. Not the least is the repeatedly cited report of the World Healh Organisation whose two first sentences contain an error and a misquotation...[11].

Lebanese independent researchers have acknowledged the existence of the overall critique of the numerous scientific errors contained in the WHO report [12]. As with other WHO dubious recommendations [13], no independent researcher (from both the tobacco and pharmaceutical industries) can consider the above-mentioned document as a solid reference. The same goes for its recycled version, the Cochrane Review on « « waterpipe » » smoking (by Maziak et al, the very authors of the WHO report), still containing serious errors but also cited by Akl et al.

Concerning the referred to “standardiz[ed] questionnaire items for the assessment of waterpipe tobacco use”(Maziak et al), this document is in fact quite arbitrary and therefore just not more “standardised” than the US-American University of Beirut smoking machine (Shihadeh et al) uncritically cited by all antismoking researchers as Gospel Truth.
It is not [14].

This is an epistemological vicious circle when anybody can decide what is standardised and what is not. The scientific method implies that a consensus be reached and the main obstacle to this is publication bias [4].

There would be many other things to say, including the fact that most of the carefully selected studies are about a type of smoking mixture and amounts of daily smoking that are completely inexistent or uncommon outside Asia and Africa. Yet, this fact (together with other striking ones such as the completely different chemical composition [high proportions of water and glycerol, unlike regular cigarettes] of shisha smoke) has been stressed in many relevant publications [4].

Tobacco smoking is a hazardous behaviour. If it is time for anything, it is to make tabula rasa of research on this topic and realise that when science turns authoritarian, the credibility of public intervention is at stake [15][16].

Dr Kamal Chaouachi



[1] Akl EA, Aleem S, Gunukula SK, Honeine R, Abou Jaoude P, Irani J. Survey instruments used in clinical and epidemiological research on waterpipe tobacco smoking: a systematic review. BMC Public Health. 2010 Jul 13;10(1):415.

[2] Akl E, Gaddam S, Gunukula SK, Honeine R, Abou Jaoude P, Irani J. The effects of waterpipe tobacco smoking on health outcomes: a systematic review. International Journal of Epidemiology. Advance Access published online on March 4, 2010. Doi:10.1093/ije/dyq002

[3] Raad D, Gaddam S, Schunemann HJ, Irani J, Abou Jaoude P, Honeine R, Akl EA. Effects of waterpipe tobacco smoking on lung function: a systematic review and meta-analysis. Chest. published 29 July 2010. Doi: 10.1378/chest.10-0991

[4] Chaouachi K, Sajid KM. A critique of recent hypotheses on oral (and lung) cancer induced by water pipe (hookah, shisha, narghile) tobacco smoking. Med Hypotheses 2010; 74: 843–6. Doi:10.1016/j.mehy.2009.11.036

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

[6] Ben Saad H. Le narguilé et ses effets sur la santé. Partie I : le narguilé, description générale et propriétés [The narghile and its effects on health. Part I: The narghile, general description and properties]. Rev Pneumol Clin 2009 Dec;65(6):369-75. Doi : 10.1016/j.pneumo.2009.08.010

[7] Ben Saad H. Le narguilé et ses effets sur la santé. Partie II : les effets du narguilé sur la santé [The narghile and its effects on health. Part II: The effects of the narghile on health]. Rev Pneumol Clin. 2010 Apr;66(2):132-44. Epub 2009 Nov 6. Doi : 10.1016/j.pneumo.2009.08.011

[8] Neergaard J, Singh P, Job J, Montgomery S. Waterpipe smoking and nicotine exposure: A review of the current evidence. Nicotine Tob Res. 2007 Oct;9(10):987-94.

[9] Chaouachi K. Clarification about bladder cancer and shisha smoking in Egypt. Cancer Epidemiology (The International Journal of Cancer Epidemiology, Detection, and Prevention) 2010 ; 34: 220. Doi: 10.1016/j.canep.2010.01.001

[10] Ben Saad H, Khemiss M, Bougmiza I, Prefaut C, Aouina H, Mrizek N, Garrouche A, Zbidi A, Tabka Z. [Spirometric profile of narghile smokers]. Rev Mal Respir. 2009 Mar;26(3):299-314.

[11] 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. Doi:10.1186/1477-5751-5-17

[12] Salameh P, Aoun Bacha Z, Waked M. Saliva cotinine and exhaled carbon monoxide in real life waterpipe smokers: a post hoc analysis. Tobacco Use Insights 2009:2 1–10.

[13] Oxman AD, Lavis JN, Fretheim A. Use of evidence in WHO recommendations. Lancet. 2007 Jun 2;369(9576):1883-9.

[14] Chaouachi K. Public health intervention for narghile (hookah, shisha) use requires a radical critique of the related “standardised” smoking machine. Journal of Public Health [Springer Berlin/Heidelberg] 2009; 17(5): 355-9. Doi : 10.1007/s10389-009-0272-7.

[15] Chaouachi K. [Comment] Time to Make Tabula Rasa of Some Misconceptions in Research on Hookah (Narghile, Shisha) Tobacco Smoking. Tobacco Induced Diseases 2010 (2 Jul)

[16] Kenneth P. Green and Hiwa Alaghebandian. Science Turns Authoritarian. American 2010 (27 Jul).

Competing interests



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