Raad - Effects of Waterpipe Tobacco Smoking On Lung Function (CHEST)

Effects of waterpipe tobacco smoking on lung
function: a systematic review and meta-analysis

Dany Raad, Swarna Gaddam, Holger J. Schunemann, Jihad Irani, Philippe Abou
Jaoude, Roland Honeine and Elie A. Akl
Chest; Prepublished online July 29, 2010;

DOI 10.1378/chest.10-0991
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Page 1 of 36
Effects of waterpipe tobacco smoking on lung function: a systematic review and meta-
analysis
Dany Raad1, Swarna Gaddam2, Holger J. Schunemann1,3, Jihad Irani4, Philippe Abou Jaoude1,
Roland Honeine1, Elie A. Akl1,2,3
1
Department of Medicine, State University of New York at Buffalo, NY, USA
2
Department of Family Medicine, State University of New York at Buffalo, NY, USA
3
Departments of Clinical Epidemiology and Biostatistics and Medicine, McMaster University,
Hamilton Canada
4
Faculty of Health Sciences, University of Balamand, Beirut, Lebanon
Corresponding author:
Elie A. Akl, MD, MPH, PhD
Department of Medicine
State University of New York at Buffalo
ECMC-CC 142
462 Grider St.
Buffalo, NY 14215 USA
Tel: ++ 1 716-898-5793
fax: ++1 716-898-3119
email: elieakl@buffalo.edu
The authors have no conflicts of interest to declare

Page 2 of 36
Keywords: “waterpipe”, “lung function”, “spirometry”, “COPD”, “chronic bronchitis”.
Word Count (text): 2611

Page 3 of 36
Abstract
Background: While common in many Middle Eastern Countries, waterpipe smoking is
increasingly popular in Western cultures. The primary objective of this study was to
systematically review the effects of waterpipe tobacco smoking on lung function. The secondary
objective was to compare the effects of waterpipe tobacco smoking and cigarette smoking on
lung function.
Methods: We conducted a systematic review using the approach of the Cochrane Collaboration
to searching for, selecting and abstracting studies. We conducted two separate meta-analyses
comparing respectively: (1) waterpipe smokers and non-smokers, and (2) waterpipe smokers and
cigarette smokers for each of 3 spirometric measurements (Forced Expiratory Volume in the first
second (FEV1), Forced Vital Capacity (FVC), and FEV1/FVC). We used the standardized mean
difference (SMD) to pool the results.
Results: Six cross-sectional studies were eligible for this review. Compared with no smoking,
waterpipe smoking was associated with a statistically significant reduction in FEV1 (SMD = -
0.43; 95% confidence interval (CI) -0.58, -0.29; equivalent to a 4.04% lower FEV1%), and a
trend toward lower FVC (SMD = -0.15; 95% CI -0.34, 0.04; equivalent to a 1.38% reduction in
FVC%), and FEV1/FVC (SMD = -0.46; 95% CI -0.93, 0.01; equivalent to a 3.08% lower
FEV1/FVC). Comparing waterpipe smoking with cigarette smoking, there was no statistically
significant difference in FEV1, FVC, and FEV1/FVC. The six studies suffered from
methodological limitations.

Page 4 of 36
Conclusion: Waterpipe tobacco smoking negatively affects lung function and may be as harmful
as cigarette smoking. Waterpipe smoking, therefore, is likely to be a cause of COPD.
Word count: 248

Page 5 of 36
Background
Chronic Obstructive Pulmonary Disease (COPD) is a preventable and treatable disease
characterized by an abnormal inflammatory response of the lung to noxious particles or gases
(e.g., tobacco) leading to a progressive and non-reversible airflow obstruction1,2. COPD has
become a leading cause of mortality and morbidity throughout the world. The Global Burden of
Disease study has projected that it will become the third leading cause of death by 2020 3. The
World Health Organization (WHO) classifies COPD as the 4th leading cause of mortality in the
US 4.
The causal relationship between chronic cigarette smoking and COPD is clearly established 5-7,
with cigarette smoking being the single most important risk factor 6. A recent systematic review
showed that the prevalence of COPD is highest among male smokers who are older than 40 years
8
.
Waterpipe smoking is a form of tobacco consumption that is increasing on a global level at a
remarkable pace 9 (see Appendix 1 and Figure 1 for further details on waterpipe smoking). The
American Lung Association has described it as an “emerging deadly trend” 10. In fact, a recent
systematic review found waterpipe tobacco smoking to be possibly associated with lung cancer,
esophageal cancer, low birth weight and periodontal diseases 11.
The above referenced systematic review identified no study assessing the association of
waterpipe smoking with airways diseases in general or COPD in particular. There are however
published studies assessing the association of waterpipe smoking with lung function
measurements. Some of these measurements (i.e. Forced Expiratory Volume in the first second

Page 6 of 36
(FEV1), Forced Vital Capacity (FVC), FEV1/FVC) are considered valid surrogate measures of
COPD 12. In the absence of data on clinical disease, data on such surrogates may be useful for
both clinical and research purposes. Thus, the primary objective of this study was to
systematically review the effects of waterpipe tobacco smoking on lung function. The secondary
objective was to compare the effects of waterpipe tobacco smoking and cigarette smoking on
lung function.
Methods
Eligibility criteria
We included studies that assessed the association between waterpipe tobacco use and lung
function. Eligible studies had to include a group of individuals smoking waterpipe exclusively.
They also had to include at least one of the following two: (1) a group of non-smokers; (2) a
group of individuals practicing cigarette smoking exclusively. Our outcomes of interest were the
following three spirometric measurements: FEV1, FVC, and FEV1/FVC.
Search Strategy
In June 2008, we searched the following electronic databases starting with their dates of
inception: MEDLINE, EMBASE, and ISI the Web of Science. The appendix provides the
detailed search strategies. We also reviewed the reference lists of included and other relevant
papers and used the 'Related Articles' function in PubMed and applied no language restrictions.
Selection process

Page 7 of 36
Two reviewers independently screened titles and abstracts resulting from the search using a
standardized screening guide. We obtained the full text of citations considered as potentially
eligible by at least one of the two reviewers. Next, the two reviewers independently screened the
full texts for eligibility using a standardized and pilot tested form. Disagreements were resolved
by discussion or by a third reviewer.
Data abstraction
One reviewer abstracted data from each eligible study using a standardized and pilot tested data
abstraction form. A second reviewer verified data abstraction. They resolved disagreements with
the help of a third reviewer. The abstracted data included information about:
1. Study design and funding;
2. Population: setting and period, and participants’ characteristics;
3. Exposure: type, measurement tool, and exposure levels of participants;
4. Outcomes: measurement tool and blinding of outcome adjudicator;
5. Methodological features: selection method, information collection (measurement of exposure
and outcome), handling of confounding, participation rate, and rate of complete data;
6. Statistical results: we collected data separately for the three different exposure groups
(waterpipe smokers, cigarette smokers, non-smokers). FEV1, FVC, and FEV1/FVC were
calculated as percentages of predicted values and reported at the group level as mean and
standard deviation (SD) of these percentages.
Data analysis

Page 8 of 36
We calculated the kappa statistic to evaluate the agreement between the 2 reviewers assessing
full texts for eligibility. For each of the three spirometric measurements (FEV1, FVC, and
FEV1/FVC), we conducted two separate meta-analyses comparing respectively: (1) waterpipe
smokers and non-smokers, and (2) waterpipe smokers and cigarette smokers. Because the
populations and lung function measures differed across studies, we first calculated the
standardized mean difference (SMD) and 95% Confidence Interval (CI) for each outcome in the
individual studies. The SMD expresses a measurement in standard units rather than the original
units of measurement. We then pooled the SMDs across studies using a random effects model. In
a sensitivity analysis, we excluded studies in which the non-smokers were described as passive
smokers. We translated the pooled SMD back into mean differences using the standard deviation
for the respective spirometric outcomes derived from the National Health and Nutrition
Examination Survey (NHANES) III data 13.
We tested results for homogeneity across studies using the I2 test 14 and used the following
interpretation of the value of I2: 0–50 = low; 50–80 = moderate and worthy of investigation; 80-
100 = severe and worthy of understanding;95-100 = aggregate with major caution (Julian
Higgins, personal communication). We rated the overall quality of evidence using the Grading of
Recommendations Assessment, Development and Evaluation (GRADE) approach 15.
Results
Description of included studies
Figure 2 shows the study flow. Of 1658 identified citations , we included 6 studies 16-21, One
study reported results separately for males and females 18. All studies included a group of non-
smokers, described as passive smokers in two of the studies 19,21. All but one study included a

Page 9 of 36
group of cigarette smokers 19. All studies reported spirometric measurements. Countries in which
the studies were conducted were Turkey (n=3), Kuwait (n=1), Saudi Arabia (n=1), and Syria
(n=1).
Methodological quality of included studies
The six included studies were cross-sectional and suffered from a number of methodological
limitations. All the studies used an objective outcome evaluation (measurement by spirometry).
Authors calculated the percentage predicted spirometric values using the CICA method in 2
studies 17,20, and the Knudson and Hankinson methods in one study 21. The remaining studies did
not report any method. 16,18,19. None of the studies reported using a standardized exposure
assessment tool. Selection of subjects was either done by visiting local coffee shops 16,17,21, by
volunteer recruitment 18,19, or by a field survey 20. Only one study reported handling confounding
by matching for gender17; two other studies reported no difference between mean age for the
groups involved 19,21 . Only one study reported blinding of outcome adjudicator 16, and only one
study reported the percentages of participation (88%) and complete data (96%) 20.
Waterpipe smoking compared to non-smoking
The pooled SMD for FEV1 was -0.43 (95% CI -0.58, -0.29; I2= 24%) equivalent to a 4.04%
lower FEV1% value in the waterpipe group (figure 3). In the sensitivity analysis excluding
studies in which the non-smokers were described as passive smokers, the pooled SMD remained
statistically significant at -0.46 (95% CI -0.60, -0.31; I2=21%). The SMD for FVC was -0.15
(95% CI -0.34, 0.04; I2= 0%) equivalent to a 1.38% reduction in FVC% in the waterpipe group
(figure 4). In the sensitivity analysis, the pooled SMD was -0.19 (95% CI -0.40, 0.01; I2=0%).

Page 10 of 36
The SMD for FEV1/FVC was -0.46 (95% CI -0.93, 0.01; I2=92%), suggesting a lower percentage
predicted value in the waterpipe group, by 3.08% (figure 5). In the sensitivity analysis, the
pooled mean difference was -0.51 (95% CI -1.06, 0.05; I2=94%). The GRADE overall quality of
evidence for FEV1 was moderate; it was downgraded secondary to study limitations.
Waterpipe smoking compared to cigarette smoking (Fig. 6-8)
The pooled SMD for FEV1 between the 2 groups was 0.20 (95% CI -0.15, 0.55; I2=87%), which
translates into a non-significantly lower FEV1% by 1.88% in the cigarette smoking group (figure
6). The SMD for FVC between the 2 groups was 0.27 (95% CI 0.09, 0.44; I2=83%), which
translates into a significantly lower percentage predicted value in the cigarette smoking group, by
2.48% (figure 7). The SMD in FEV1/FVC between the 2 groups was 0.22 (95% CI -0.29, 0.73;
I2=94%), suggesting a non-significantly lower percentage predicted value in the waterpipe group,
by 1.47% (figure 8). The GRADE overall quality of evidence for FEV1 was low; it was
downgraded secondary to study limitations and imprecision.
Association between the duration of waterpipe smoking and lung function
Four studies reporting on the association between the duration of waterpipe smoking and lung
function had mixed results. Two studies reported no correlation between the duration of
waterpipe smoking and the decline in FEV1 (16,17. The other 2 studies reported an association;
one found a marked decline in FEV1 and FEV1/FVC when comparing heavy smokers (> 2
waterpipe/day) to light smokers (1-2 waterpipe/day) while the other reported a negative
correlation for cumulative quantity of waterpipe smoking with FEV1, FVC, and FEV1/FVC.

Page 11 of 36
Discussion
We systematically reviewed the scientific literature for the effects of waterpipe smoking on lung
function. Compared to no smoking, waterpipe tobacco smoking was associated with a
statistically significant reduction of FEV1 and a trend toward lower FVC and FEV1/FVC. The
quality of evidence is moderate (i.e., further research is likely to have an important impact on our
confidence in the estimate of effect and may change the estimate) 15. There were no statistically
significant differences in FEV1 and FEV1/FVC between waterpipe smokers and cigarette
smokers. The quality of evidence was low (i.e., further research is very likely to have an
important impact on our confidence in the estimate of effect and is likely to change the estimate)
15
.
Our study has a number of strengths. First, we used the comprehensive approach of Cochrane
Collaboration for conducting systematic reviews, including a very sensitive search strategy, a
duplicate and independent selection and data abstraction processes, and a rigorous evaluation of
study methodological quality. Also, by pooling results across studies we were able to obtain
relatively precise estimates of the outcomes of interest. Last, this is the first meta-analysis, to our
knowledge, that assesses the association of waterpipe smoking with lung function.
The study also has a number of limitations. While, the primary objective of this study was to
assess the effects of waterpipe tobacco smoking on lung function, the available evidence coming
from cross sectional studies provides evidence for an association but does not establish causality.
Our confidence in the results of the meta-analysis is reduced by the methodological limitations of
the included individual studies. Indeed, none of the studies used a standardized tool to measure
10

Page 12 of 36
the degree of exposures of interest (e.g., in terms of smoking patterns, frequency and lengths of
smoking sessions, the type and quality of tobacco used for both waterpipe and cigarettes
smoking). This is particularly problematic given the potential variability in exposure. Finally, all
but 2 studies failed to distinguish passive smokers from non-smokers for exposure to waterpipe
or cigarette smoking. However, the results of sensitivity analyses excluding these 2 studies were
consistent with the results of the main analyses.
The association between waterpipe smoking and reduction in FEV1 is not only statistically
significant, but also of potential clinical relevance. We can assess the clinical relevance
comparing the effect size to the minimal important difference (MID), defined as “the smallest
difference in score in the outcome of interest that informed patients or informed proxies perceive
as important, either beneficial or harmful, and which would lead the patient or clinician to
consider a change in management”. It has been suggested that the MID for FEV1 is in the range
of 100-140 ml 22. The mean difference in our study was estimated to be around 4%, which
approximates to 173 ml for a 40 years old Caucasian male of 180 cm height. Therefore, the
reduction of FEV1 associated with waterpipe smoking is clinically relevant.
The association of waterpipe smoking with a significant reduction in FEV1 suggests its
implication as a risk factor for obstructive disease. This is consistent with the finding of a trend
toward reduction in FVC and FEV1/FVC among waterpipe smokers. The lack of statistical
significance for these reductions is likely due to the lack of statistical power. Taken together,
however, these findings suggest a possible role of waterpipe smoking in the development of
COPD.
11

Page 13 of 36
There is additional evidence of the implication of waterpipe smoking in COPD. Two studies
using respectively questionnaires adapted from the Medical Research Council (MRC) and the
European Coal and Steel Community (ECSC) on the symptoms of chronic bronchitis identified
statistically significant higher number of positive responses in waterpipe smokers than in
cigarette smokers 16,20 In the first study, symptoms of chronic bronchitis were identified in
11.75% of waterpipe smokers, as compared to 9.5% of cigarette smokers, and 0% in non-
smokers16. In the second study, chronic bronchitis was found to be more prevalent in waterpipe
smokers than cigarette smokers for cumulative quantity and duration 20. Despite the limited
available data, these results help add up to the evidence of the risk of development of COPD in
waterpipe smokers.
While the results of FEV1 and FEV1/FVC comparing waterpipe to cigarette smoking show no
statistical difference, they suffered from a high level of heterogeneity. The most likely
explanation for this heterogeneity is the variation of levels of exposure to the 2 forms of
smoking. While the effect on lung function is associated with the levels of exposure to cigarette
smoking and (likely) waterpipe smoking, the degree of exposure was not measured. It is also
possible that that the lack of observed difference between waterpipe smokers and cigarette
smokers may be due to inadequate power.
Some authors have hypothesized a less important effect of waterpipe smoking compared with
cigarette smoking on lung function based on a number of assumptions: the inability of smoke to
reach the lower airways because of the smoking pattern and because of the filtration of smoke by
12

Page 14 of 36
the water; and a better healing of small airway inflammation because of intermittent nature of
smoking, 17,19. Our study found no statistically significant difference in FEV1 and FEV1/FVC
between the 2 forms of smoking. Indeed, recent evidence has shown that water does not
significantly filter out the nicotinic products produced by waterpipe smoking 23. Also, waterpipe
smokers have an elevation in the level of parameters of oxidation injury and a decreased total
antioxidant activity 24,25. The resulting oxidative stress is thought to play a very important role in
the pathogenesis of COPD 1.
Conclusion
Implications for public health policy
This study adds to the rapidly growing evidence of the association of waterpipe tobacco smoking
with deleterious health outcomes 11, which has very important implications for the both clinical
and public health practice. Spirometry performance might give the clinician an opportunity to
convince smokers to quit 26. More importantly, our study supplies the clinician with data they
might use in counseling patients about the deleterious effect of waterpipe smoking on lung
function. As for the public health practice, this study illustrates that waterpipe smoking may be
as harmful as cigarette smoking in terms of lung function. Public health policy makers need to
aggressively address the epidemic of waterpipe smoking in terms of raising awareness and
advocating for appropriate policy changes.
Implications for research
As it has already been advised by the World Health Organization (WHO), there is a need for
more research related to waterpipe 27. Specifically, there is a need for higher quality prospective
13

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studies that could more clearly identify the causal relationship between waterpipe smoking and
clinical outcomes. Similarly, there is a need for exploring whether quitting smoking slows down
or reverses the deterioration of lung function. Finally, researchers need to focus on standardizing
the exposure measurement tools in order to reliably assess for dose-response relationships 28.
14

Page 16 of 36
Acknowledgments
We would like to thank Ann Grifasi for her administrative assistance, Dr. Monique Chaaya, Dr.
Yousser Mohammad, Dr Sana Al Mutairi, Dr. Nalan Koseoglu for their correspondence with
results, and Dr. Sameer Gunukula for his help in formatting the table.
DR contributed to study selection, data abstraction data analysis, data interpretation, and
drafting of the manuscript. SG contributed to study data abstraction. HJS contributed to data
interpretation. PAJ and RH screened title and abstracts, and full texts. JI contributed to drafting
the protocol and designing the search strategy. EAA contributed to drafting the protocol,
designing the search strategy, developing the forms, screening, data abstraction, data analysis,
data interpretation, and drafting of the manuscript. All authors revised the article critically for
important intellectual content and approved the final version of this manuscript.
15

Page 17 of 36
Figure legends
Figure 1: Annotated figure of a waterpipe device
Figure 2: Study flow diagram
Figure 3: Comparison of FEV1 in waterpipe smokers and non-smokers
Figure 4: Comparison of FVC in waterpipe smokers and non-smokers
Figure 5: Comparison of FEV1/FVC in waterpipe smokers and non-smokers
Figure 6: Comparison of FEV1 in waterpipe smokers and cigarette smokers
Figure 7: Comparison of FVC in waterpipe smokers and cigarette smokers
Figure 8: Comparison of FEV1/FVC in waterpipe smokers and cigarette smokers
16

Page 18 of 36
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18

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Tables 1: Characteristics of included studies measuring the association between waterpipe tobacco smoking and lung function
Study Population Exposure Outcome Methodological Results

characteristics
Kiter, 2000 Pulmonary Function:
• Setting and period: special • Type: waterpipe, cigarette • Selection: waterpipe • FEV1, FVC,
• Study cafes in Izmir City (Turkey), • Measurement: self developed • Measurement tool: smokers selected from and FEV1/FVC
design: period not reported tool, no standardization portable spirometer special cafes, non-
cross- • Participants’ characteristics: reported; personal interview according to the cigarette smokers and significantly
sectional standards of the non-smokers selected lower in
100% males o Waterpipe cumulative

study American Thoracic randomly from cafes waterpipe
o Waterpipe smokers: 82 consumption measured as
society; percentage and outside cafes smokers than
• Funding: subjects, age 56±10 years number of jurak-years =
non-smokers
not reported o Cigarette Smokers: 103 number of jurak smoked/day predicted values • Information
x number of smoking years. calculated automatically collection: objective • FEV1 and
subjects, age 46±14 years
according to CECA outcome evaluation, FEV1/FVC
o Waterpipe smokers who quit o Cigarette cumulative
method non standardized significantly
cigarette smoking: 95 consumption measured as
Pack years = number of • Blinding of outcome exposure assessment lower in
subjects, age 54±12 years
cigarette packs smoked/day adjudicator: not reported tool cigarette
o Non-smokers: 117 subjects • Confounding smokers than
age, 46±16 years x number of smoking years
handling: matching waterpipe
• Exposure levels of smokers
participants: done for gender only
• % participation: not • FVC non-
o Waterpipe smokers: 47±33 significantly
jurak years reported
lower in
o Waterpipe smokers who quit • % complete data: not
cigarette
cigarette smoking: 37±42 reported
smokers than
jurak-years and 38±32 waterpipe
pack-years smokers
o Cigarette Smokers: 38±30 • There was
pack-years negative
correlation of
pack-years with
FEV1 in
0
Page 21 of 36
cigarette
smokers, but
no correlation
between FEV1
and jurak-years
in waterpipe
smokers
Al Fayez • Setting and period: Saudi • Type: waterpipe, cigarette Pulmonary Function: • Selection: volunteer • FEV1, FVC,
1988 Arabia, period not reported • Measurement: self developed • Measurement tool: time recruitment and FEV1/FVC
• Study • Participants’ characteristics: tool, no standardization revolving spirogram • Information significantly

design: age 20-59 years in males and reported; personal interview (Vitalograph); method of collection: objective lower in
cross- 17-59 years in females. calculation of percentage outcome evaluation, waterpipe
• Exposure levels of
sectional Subjects with history of asthma, participants: not reported predicted values not non standardized smokers than
study chronic bronchitis, or any reported exposure assessment non-smokers
• Funding: cardiopulmonary diseases • Blinding of outcome tool • FEV1 and FVC
King excluded. adjudicator: not reported • Confounding significantly
AbdulAziz o Waterpipe smokers: 344 handling: No lower in males
City for subjects, 73% males matching or and non-
Science and o Cigarette Smokers: 251 adjustment in the significantly
Technology subjects,75% males analysis reported lower in
females in
o Non-smokers: 283 subjects, • % participation: not
cigarette
58% males reported
smokers than
• % complete data: not waterpipe
reported smokers
• FEV1/FVC
significantly
lower in both
males and
females in
cigarette
smokers than
waterpipe
1
Page 22 of 36
smokers
• Heavy
waterpipe
smokers (>2
waterpipe/day)
exhibited a
marked decline
in FEV1 and
FEV1/FVC
compared to
light smokers
(1-2
waterpipe/day)
Al Mutairi • Setting and period: local • Type: waterpipe, cigarette Pulmonary Function: • Selection: subjects • FEV1 and
2006 coffee shops and university • Measurement: self developed • Measurement tool: were selected from FEV1/FVC
• Study students in Kuwait, period not tool, no standardization Jaeqar Masterlab local coffee shops and non-
design: reported reported; constructed spirometry; method of among university significantly
cross- • Participants’ characteristics: questionnaire that identifies calculation of percentage students lower in
sectional all subjects who smoked more smoking behavior of both predicted values not • Information waterpipe
study than one kind of tobacco, and groups, detailing rate of reported collection: objective smokers than
who had chronic consumption of tobacco/day outcome evaluation, non-smokers
• Funding: • Blinding of outcome
Kuwait cardiopulmonary or renal Objective measurement tool adjudicator: yes non standardized • FEV1, FVC,
University diseases, or who were on : urinary cotinine and nicotine exposure assessment and FEV1/FVC
Research regular medications, were level tool non-
administrati excluded from the study • Confounding significantly
on Grant o Waterpipe smokers: 77 handling: No lower in
participants:
subjects, 90% males, age matching or waterpipe
o Waterpipe smokers: smokers than
36.97 (34.79-39.16) years adjustment in the
• Age of starting smoking analysis reported cigarette
o Cigarette Smokers: 75
24.89 (22.61-27.17) years smokers
subjects, 93% males, age • % participation: not
37.73 (35.54-39.95) years • Urinary nicotine = 440.48 reported • There was no
o Non-smokers: 16 subjects, (197.06-683.91) ng/mL significant
• % complete data: not
2
Page 23 of 36
56% males, age 33.3 (28.9- • Urinary cotinine = 677.62 reported difference in
37.76) years (458.89-896.34) ng/mL FEV1 and
o Cigarette smokers: FEV1/FVC
values in
• Age of starting smoking
relation to
20.36 (18.55-22.17=8)
duration of
years
smoking (<10
• Urinary nicotine = 1487.30 years vs. >10
(839.26-2135.37) ng/mL years) in both
• Urinary cotinine = cigarette and

1321.35 (1003.73- waterpipe
1638.98) ng/mL smokers
Aydin, 2004 • Setting and period: Turkey, • Type: waterpipe Pulmonary Function: • Selection: volunteer • FEV1, FVC,
• Study period not reported • Measurement: self developed • Measurement tool: recruitment and FEV1/FVC
design: • Participants’ characteristics: tool, no standardization Sensor Media V max 22); • Information non-
cross- all subjects had no significant reported; personal interview method of calculation of collection: objective significantly
sectional lung or other system disease or • Exposure levels of percentage predicted outcome evaluation, lower in
study cigarette smoking history values not reported non standardized waterpipe
participants:
exposure assessment smokers than
• Funding: o Waterpipe smokers: 14 o Waterpipe smokers: • Blinding of outcome
tool non-smokers
not reported subjects, 100% males, age 23.7±8.7 years adjudicator: not reported
53.7± 9.8 years • Confounding
o Passive smokers: 21.3±5.2
o Passive smokers: defined as handling: matching
years
individuals who do not smoke not reported but
but are exposed to intensive author reports no
cigarette smoke in the living significant difference
or working environment: 11 between the mean
subjects,91% males, age age of the 2 groups
43.8 ±12.9 years • % participation: not
reported
• % complete data: not
reported
3
Page 24 of 36
Mohammad, • Setting and period: Syria, first • Type: waterpipe, cigarette Pulmonary Function: • Selection bias: • FEV1, FVC
2008 semester of 1994-1995 • Measurement: self developed • Measurement tool: subjects recruited by and FEV1/FVC
• Study • Participants’ characteristics: pilot tested tool, no further automatic calibrated field survey significantly
design: 100% females, all subjects had validation reported spirometer; percentage • Information lower in
cross- predicted values waterpipe
no co-morbidity, no respiratory o Waterpipe cumulative collection: objective

sectional symptoms related to factors calculated automatically outcome evaluation, smokers than
consumption calculated
study other than smoking, and no according to CECA non standardized non-smokers
using: Q = S.q (g).T
• Funding not exposure to other risk factors in (days)/1000 method exposure assessment • FEV1, FVC
reported her daily life; none of the • Q = Cumulative quantity • Blinding of outcome tool and FEV1/FVC
subjects smoked both smoked in kg. adjudicator: not reported • Confounding significantly
waterpipe and cigarettes • S = Number of sessions handling: No lower in
• FEV1: considered
o Waterpipe smokers: 77 per day. matching or cigarette
abnormal of < 80%
subjects, age 40.99±12.54 • q = Quantity smoked per adjustment in the smokers than
• FEV1/FVC: considered to waterpipe
o Cigarette Smokers: 77 session in grams. analysis reported
reflect obstruction if < smokers
subjects, age 44.84±10.55 • T = Duration of smoking in • % participation: 88%
70%
days. • There was a
o Non-smokers: 100 subjects, • % complete data:
• n = number of smokers per negative
age 39.13±12.898 96%
session. correlation for
o Cigarette cumulative cumulative
consumption calculated quantity of both
using: Q = N (g).T cigarette and
(days)/1000 waterpipe
• Q = Cumulative quantity smoking with
smoked in Kg. FEV1, FVC,
• N = Number of cigarettes and
per day FEV1/FVC.
• T = Duration of smoking in
days.
participants:
o Waterpipe smokers: 58±3.8
Kg, 60 ±3.81 years
4
Page 25 of 36
o Cigarette smokers: 40±3.8

Kg, 38±3.81 years
Koseoglu • Setting and period: local • Type: waterpipe, cigarette Pulmonary Function: • Selection: subjects • FEV1, FVC,
2006 coffee shops in Izmir City • Measurement: self developed • Measurement tool: were selected from and
• Study (Turkey), period not reported tool, no standardization spirometer (Sensor local coffee shops FEV1/FVC
design: • Participants’ characteristics: reported; personal interview Medics V-Max) according • Information non-
cross- all subjects who had history of to the American Thoracic collection: objective significantly
Objective measurement tool
sectional systemic or pulmonary disease, Society; percentage outcome evaluation, lower in
(urinary cotinine level)
study predicted values waterpipe
COPD, lung cancer, previous non standardized

• Exposure levels of smokers than
• Funding not lung surgery, common cold or calculated according to exposure assessment
participants: non-smokers
reported viral respiratory disease, allergy Knudson and Hankinson tool
history, history of active o Waterpipe smokers: methods • FEV1, FVC,
• Confounding
pulmonary infection, or taking • Average amount of • Blinding of outcome handling: matching and
medications that increase or tobacco = 35.5±22.8/year adjudicator: not reported not reported, authors FEV1/FVC
decrease mucociliary clearance • Urinary cotinine 838.9 report no significant non-
were excluded. ±762.5 ng/mL difference in age, significantly
o Waterpipe smokers: 20 height, weight, and lower in
o Cigarette smokers:
subjects, age 56.1±8.4 years BSA cigarette
• Average amount of smokers than
o Cigarette Smokers: 23 tobacco = 36.2±23.1 • % participation: not
subjects, age 52.0 ± 5.7 waterpipe
pack-years reported
years smokers
• Urinary cotinine • % complete data: not
o Passive smokers: 15 1576±974.9 ng/mL reported
subjects, age 54.5±19 years
5
Page 26 of 36
Appendices
Appendix 1: Description of waterpipe smoking
Waterpipe tobacco smoking is traditional to the region of the Middle East. A waterpipe device
consists of 3 main parts: the head, body, and glass bowl along with a hose and a mouthpiece
(Figure 1). The glass bowl which is usually half-filled with water is connected to the head by a
long tube that allows delivery of the smoke by high suction pressure. Instead of burning the
tobacco, as in cigarette smoking, the waterpipe device heats it using charcoal at an ignition
temperature of 308°C. It then uses water to filter the smoke before its inhalation. As a result of
incomplete combustion of tobacco leaf, several gaseous compounds like carbon monoxide (CO),
nitrosamine, and hydrogen cyanide, as well as particulate compounds like tar and nicotine are
released into the main stream. The mouthpiece is then used to inhale the smoke through the hose.
Intermittent rapid and shallow inhalations are usually needed in order to inhale the smoke and
keep the tobacco burning.

Page 27 of 36
Appendix 2: Electronic search strategies
MEDLINE (1950 onward)
Waterpipe*.mp.
“water pipe*”.mp.
shisha*.mp.
sheesha*.mp.
hooka*.mp.
huqqa*.mp.
guza*.mp.
goza*.mp.
narghil*.mp.
nargil*.mp.
arghil*.mp
argil*.mp
(hubbl* adj3 bubbl*).mp.
or/1-13
EMBASE (1988 onward)
Waterpipe*.mp.
“water pipe*”.mp.
shisha*.mp.
sheesha*.mp.

Page 28 of 36
hooka*.mp.
huqqa*.mp.
guza*.mp.
goza*.mp.
narghil*.mp.
nargil*.mp.
arghil*.mp
argil*.mp
(hubbl* adj3 bubbl*).mp.
or/1-13
ISI the Web of Science
(waterpipe* OR "water pipe*" OR shisha* OR sheesha* OR hooka* OR huqqa* OR guza* OR
goza* OR narghil* OR nargil* OR argil* OR arghil* OR (hubbl* SAME bubbl*)) AND
(smoking OR smoke OR health OR disease OR cancer* OR malignan* OR lung* OR
pulmonary OR heart OR cardiac OR vascular OR stroke) (in Title or Topic)

Page 29 of 36
Annotated figure of a waterpipe device

123x153mm (96 x 96 DPI)

Page 30 of 36
Study flow diagram

166x139mm (96 x 96 DPI)

Page 31 of 36
Comparison of FEV1 in waterpipe smokers and non-smokers

244x59mm (96 x 96 DPI)

Page 32 of 36
Comparison of FVC in waterpipe smokers and non-smokers

244x46mm (96 x 96 DPI)

Page 33 of 36
Comparison of FEV1/FVC in waterpipe smokers and non-smokers

244x59mm (96 x 96 DPI)

Page 34 of 36
Comparison of FEV1 in waterpipe smokers and cigarette smokers

237x55mm (96 x 96 DPI)

Page 35 of 36
Comparison of FEV1 in waterpipe smokers and cigarette smokers

237x46mm (96 x 96 DPI)

Page 36 of 36
Comparison of FEV1/FVC Comparison of FVC in waterpipe smokers and cigarette smokers

237x55mm (96 x 96 DPI)

Effects of waterpipe tobacco smoking on lung function: a systematic review
and meta-analysis
Dany Raad, Swarna Gaddam, Holger J. Schunemann, Jihad Irani, Philippe Abou
Jaoude, Roland Honeine and Elie A. Akl
Chest; Prepublished online July 29, 2010;
DOI 10.1378/chest.10-0991
This information is current as of April 8, 2011
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Raad - Effects of Waterpipe Tobacco Smoking On Lung Function (CHEST)

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Raad - Effects of Waterpipe Tobacco Smoking On Lung Function (CHEST)

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Effects of waterpipe tobacco smoking on lung

function: a systematic review and meta-analysis

Chest; Prepublished online July 29, 2010;

CHEST Papers in Press are peer-reviewed, accepted articles that have

Downloaded from chestjournal.chestpubs.org at Suny at Stony Brook on April 8, 2011

Roland Honeine1, Elie A. Akl1,2,3

Elie A. Akl, MD, MPH, PhD

State University of New York at Buffalo

462 Grider St.

Buffalo, NY 14215 USA

fax: ++1 716-898-3119

The authors have no conflicts of interest to declare

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Keywords: “waterpipe”, “lung function”, “spirometry”, “COPD”, “chronic bronchitis”.

Word Count (text): 2611

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Background: While common in many Middle Eastern Countries, waterpipe smoking is

difference (SMD) to pool the results.

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as cigarette smoking. Waterpipe smoking, therefore, is likely to be a cause of COPD.

Word count: 248

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Chronic Obstructive Pulmonary Disease (COPD) is a preventable and treatable disease

characterized by an abnormal inflammatory response of the lung to noxious particles or gases

Waterpipe smoking is a form of tobacco consumption that is increasing on a global level at a

esophageal cancer, low birth weight and periodontal diseases 11.

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following three spirometric measurements: FEV1, FVC, and FEV1/FVC.

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by discussion or by a third reviewer.

1. Study design and funding;

2. Population: setting and period, and participants’ characteristics;

3. Exposure: type, measurement tool, and exposure levels of participants;

4. Outcomes: measurement tool and blinding of outcome adjudicator;

5. Methodological features: selection method, information collection (measurement of exposure

standard deviation (SD) of these percentages.

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FEV1/FVC), we conducted two separate meta-analyses comparing respectively: (1) waterpipe

Examination Survey (NHANES) III data 13.

Recommendations Assessment, Development and Evaluation (GRADE) approach 15.

Description of included studies

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Methodological quality of included studies

Waterpipe smoking compared to non-smoking

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Waterpipe smoking compared to cigarette smoking (Fig. 6-8)

downgraded secondary to study limitations and imprecision.

Association between the duration of waterpipe smoking and lung function

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function. Compared to no smoking, waterpipe tobacco smoking was associated with a

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consistent with the results of the main analyses.

reduction of FEV1 associated with waterpipe smoking is clinically relevant.

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statistically significant higher number of positive responses in waterpipe smokers than in

11.75% of waterpipe smokers, as compared to 9.5% of cigarette smokers, and 0% in non-

smokers may be due to inadequate power.

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the pathogenesis of COPD 1.

Implications for public health policy

advocating for appropriate policy changes.

Implications for research

(waterpipe* OR "water pipe" OR shisha OR sheesha* OR hooka* OR huqqa* OR guza* OR