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Hookah (waterpipe) smoking is a growing tobacco epidemic. Though perceived as a safer tobacco alternative, hookah smoke contains, in addition to tobacco combustion products, large amounts of charcoal combustion products-implicated in cardiovascular disease-from the burning charcoal used to heat the flavored tobacco. To date, little is known on the vascular effects of hookah smoking. The aim of this study was to characterize the peripheral circulatory response to acute hookah smoking in cutaneous and muscular beds. In 21 healthy young adult habitual hookah smokers who did not smoke cigarettes (age 24 ± 1 years, mean ± SE), we measured plasma nicotine, exhaled carbon monoxide, skin blood flow (laser Doppler velocimetry) and calf muscle blood flow (strain-gauge plethysmography) before and for up to 60 minutes after ad lib hookah smoking. In nine subjects, nonsmoking time-control studies were performed. Hookah smoking, which increased plasma nicotine by 5.8 ng/ml (from 0.6 ± 0.1 to 6.4 ± 1.3, p0.001) and exhaled carbon monoxide by 27 ppm (from 2.7 ± 0.2 to 29.5 ± 2.2, p0.001), decreased skin blood flow by 23% (20.1 ± 2.8 to 14.8 ± 1.9 units, p0.001) and increased skeletal muscle blood flow by 34% (2.3 ± 0.1 to 2.9 ± 0.2 units, p = 0.010). These responses required more than one hour to recover after smoking cessation. All cardiovascular parameters were unchanged in the nonsmoking time-control studies. Although perceived to be innocuous, hookah smoking produces acute cutaneous vasoconstriction with skeletal muscle vasodilation, a dissociated pattern of peripheral blood flow responses that is characteristic of nicotine and carbon monoxide. In conclusion, these findings provide objective evidence to challenge the perception that hookah smoking is a safer tobacco alternative.

Hookahs, or water pipes, are ornate glass bowl structures used to smoke tobacco products, often in private or public social settings. Hookah smoking is believed to have originated in ancient India in the 16th century; however, it has seen rapid global expansion over the last two decades. A number of studies using high-cost, regulatory or research grade instruments have found respirable particulate concentrations in hookah lounges up to several hundred micrograms per cubic meter. In the summer of 2018, a study was initiated examining the PM2.5 concentrations in several hookah lounges in Nablus and Tulkarm, Palestine (West Bank). However, rather than using the typical high-cost system, low-cost laser light scattering and detection systems were used. Observed PM2.5 concentrations ranged from 84 to 371 μg/m3, concentrations considered to be of notable health concerns in the indoor environment and well within the range of hookah-related particulate matter reported in the literature. Further, examination of the 10-min average temporal PM2.5 concentrations showed variable correlation with the number of active smokers and a seeming dependency on the type of building ventilation. The employed low-cost particulate systems proved capable of reliably quantifying PM2.5 levels in a variety of hookah lounges, as well as being able to characterize the temporal nature of the PM2.5 concentration changes. The results of this study suggest that these systems may be an economic and reliable alternative for particulate studies.

Objectives Electronic cigarettes (e-cigarettes) and waterpipes are gaining in popularity among adolescents in tandem with the increasing popularity of social networking sites (SNSs). The objective of this study was to examine the associations between the use of SNSs and e-cigarette and waterpipe use among adolescents, and to test whether these associations are independent of tobacco cigarette smoking. Study design A province-wide school-based cross-sectional study. Methods Data were derived from the 2013 Ontario Student Drug Use and Health Survey. Our analyses included representative data from 2841 high school students across Ontario, Canada, who completed the questionnaire that included measures of lifetime use of e-cigarette and past-year use of waterpipe. Results Nearly 14.6% of students reported having smoked an e-cigarette in their lifetime and 12.2% reported having smoked a waterpipe in the past year. After adjusting for various covariates, daily use of SNSs of at least 1 h/day was associated with greater odds of e-cigarette use (odds ratios ranged from 3.31 for SNS use of 1 h/day to 3.43 for ≥3 h/day), while daily use of SNSs of at least 2 h was associated with waterpipe use (odds ratios of 3.28 for SNS use of 2 h/day and 2.83 for use of ≥3 h/day). The observed associations remained significant after further adjusting for tobacco cigarette smoking. Conclusions The use of SNSs was positively associated with e-cigarette and waterpipe use, independent of tobacco cigarette smoking. These findings highlight the need for including SNSs in ongoing prevention and intervention efforts.

This study aimed to determine the prevalence and factors associated with hookah smoking and perceptions of harm among U.S. adults. Data were pooled from the Tobacco Products and Risk Perceptions Surveys conducted separately in the summers of 2014 and 2015, among a probability sample selected from an online research panel. Descriptive, logistic regression, and multinomial logistic regression analyses were conducted. In 2014/2015, prevalence of ever and past 30-day hookah smoking among U.S. adults were 15.8% (95% C.I.: 15.0%, 16.7%) and 1.5% (95% C.I.: 1.2%, 1.8%), respectively. Adults who used other alternative tobacco products had a higher odds of hookah smoking than those who did not. Adults with some college education (AOR, 1.53) and with a college degree or more (AOR, 2.21), those identified as non-Hispanic other (AOR, 1.38) were more likely to be ever hookah smokers. Being a young adult (AOR, 2.7), college-educated (AOR, 2.3), never smoker (AOR, 2.1), and an ever hookah smoker (AOR, 2.8) were associated with lower perceptions of harm. Findings suggest that young college students are at higher risk of smoking hookah and that hookah smoking is more prevalent among individuals who use other tobacco products, such as little cigars and cigarillos, traditional cigars, and e-cigarettes, indicating a distinct group of users of alternative tobacco products. Regarding potential harm of hookah, the study highlights a knowledge gap and misperception especially among young, college-educated, and never smokers. Public health interventions should target these subpopulations to provide them with accurate information on hookah smoking.

Introduction Hookah smoking has recently become a common form of smoking, and its prevalence has increased worldwide. This study determined the prevalence and correlates of hookah awareness and perceived harmfulness among U.S. adults. Methods Weighted multivariable logistic regression analyses were performed on 6,711 adults aged ≥18 years collected from the 2013–2014 Health Information National Trends Survey (Cycles 3 and 4). Analysis was conducted in 2016. Results Overall, 74.3% were aware of hookah. Of these, 73.4% believed hookah pipes were equally harmful as cigarettes whereas 15.7% believed otherwise. Older (OR=0.13, 95% CI=0.09, 0.18), black (OR=0.51, 95% CI=0.38, 0.71), Hispanic (OR=0.52, 95% CI=0.37, 0.71), and less-educated (OR=0.42, 95% CI=0.27, 0.65) respondents had lower odds of being aware of hookah. Compared with non-smokers, former smokers had 83% (95% CI=1.44, 2.33) higher odds of hookah awareness. Among those aware of hookah, older (OR=0.44, 95% CI=0.31, 0.62), black (OR=0.64, 95% CI=0.43, 0.96), and less-educated (OR=0.55, 95% CI=0.33, 0.92) respondents had lower odds of perceiving hookah as less harmful than cigarettes. Conclusions Most adults in U.S. are aware of hookah, but only 15.7% believe it is less harmful than cigarettes. This small proportion are mostly young, white, and college graduates. Targeted behavioral interventions will be necessary to increase individuals’ perceived risk, knowledge, and perceived harmfulness of hookah smoking.

This work offers a preliminary investigation of the compounds in smoke from hookah tobacco and tobacco-free steam stone products. A preconcentration extraction method involving headspace solid phase microextraction (SPME) and gas chromatography mass spectrometry (GC–MS) was developed for the qualitative analysis of condensed hookah smoke (CHS). A simulated hookah apparatus was constructed to smoke hookah tobacco or steam stones with coconut, wood, or electronic charcoals used as the heat source. The vapor was collected by condensing the mainstream smoke as it passed through a 15 mL vacuum cold trap vial inside an acetonitrile/dry ice cold bath at − 40 °C. Multiple SPME fibers (a 50/30 μm DVB/CAR®/PDMS fiber, a 65 μm PDMS/DVB fiber, an 85 μm CAR®/PDMS fiber, a 100 μm PDMS fiber, and an 85 μm Polyacrylate fiber) were used to qualitatively screen compounds present in the highly complex hookah smoke condensate. An in-house reference composed of 3R4F reference cigarettes was used to estimate SPME extraction and desorption times (5 min and 1 min, respectively). Chromatograms indicated that the hookah tobacco condensate contained more compounds than the steam stone condensate and a preliminary attempt was made to assign peaks to their source compounds using mass spectral information. Principal component analysis (PCA) of peak signal intensities suggested that the 65 μm PDMS/DVB, 85 μm CAR®/PDMS, and 85 μm Polyacrylate fibers extracted tobacco and steam stone volatile organic compounds (VOCs) most consistently. The complexity of hookah tobacco and steam stone smoke limits our ability to quantify the compounds at this time, however identification and quantitation will be the focus of future work.

A man in his 20s with no medical history presented with 2 days of progressively worsening shortness of breath accompanied by subjective fevers, chills, body aches, decreased appetite, night sweats, and cough producing nonbloody sputum. He denied childhood lung diseases, allergies, or a family history of lung disease. He did not smoke cigarettes but had smoked hookah in Saudi Arabia before moving to the United States 1 month before presentation and had restarted 2 days before the start of symptoms. He denied travel outside of the northeastern United States. He did not take medications, use illicit drugs, or engage in high-risk behavior.

Objectives This study aims to examine current hookah users' perceptions, attitudes, and normative beliefs regarding hookah smoking to further elucidate the rise in hookah smoking prevalence among young adults (aged 18–24 years) and reveal why hookah smoking is perceived as less harmful than other forms of tobacco consumption. Study design Qualitative. Methods Data from six focus group interviews with hookah smokers aged between 18 and 24 years were analyzed using a grounded theory approach. Focus groups were evenly split between frequent and infrequent hookah users, and were predominantly composed of college students, with two groups of hookah users consisting of 18–24 year olds of non-student status. Results Hookah users shared a much larger set of positive hookah smoking behavioral beliefs as opposed to negative behavioral beliefs. Generational traits served as the overarching commonality among the behavior performance initiation determinants observed. The most notable generational trends observed were within the cultural category, which included the following millennial characteristics: autonomy, personalization, novelty appeal, convenience, globally oriented, entertainment, collaboration, health conscious, and valuing their social network. Conclusions Millennial hookah users revealed mindfulness regarding both potential negative and positive reasons stemming from continued hookah use; however, behavioral beliefs were primarily fixated on the perception that hookah smoking was a healthier alternative to cigarette smoking. Future implications for this study's findings include generating more positive ways to express these traits for young adults; policy implications include raising hookah bar age limits, implementing indoor smoking restrictions, and limiting the ease of accessibility for purchasing hookah supplies.

Objective Hookah consumption, as a common non-cigarette tobacco product, is wrongly considered as less harmful. Moreover, little is known about hookah consumption and risk of ischemic stroke. The current study aimed to assess the association between hookah consumption and first-ever ischemic stroke (FEIS). Methods This case-control study was performed on individuals admitted at a tertiary referral center in Shiraz, Southern Iran between October 1, 2018 and September 20, 2019. We compared FEIS patients with randomly selected stroke-free individuals as a control group. Using a multiple logistic regression analysis, we assessed the association between hookah consumption and FEIS. Results A total of 208 FEIS patients (mean age 65.2 ± 15.9 years) and 212 age and sex-matched controls (mean age 63.2 ± 14.4) were recruited. The prevalence of vascular risk factors and comorbidities including ischemic heart disease, hypertension, diabetes mellitus, dyslipidemia, atrial fibrillation, cigarette smoking, and sleep apnea was higher in patients with FEIS than their control counterparts. After adjusting for a wide range of confounders, including socioeconomic factors, hookah consumption was still an independent risk factor for FEIS (odds ratio: 3.2, 95% CI: 1.7–6.1). Conclusion Hookah consumption is associated strongly with FEIS. Public awareness about risk of hookah consumption should be raised.

In the summer of 2009, the FDA obtained authority to regulate the manufacturing, distribution, and marketing of cigarettes and smokeless tobacco products. The Family Smoking Prevention and Tobacco Control Act was passed to reduce the trend of new users forming an addiction to tobacco before they were of the age to have an understanding of the toxic and even deadly consequences. However, non-conventional tobacco products, such as hookah tobacco, e-cigarettes, and other modified tobacco or tobacco-free alternatives are currently not regulated. On April 24th, 2014, the FDA announced they were planning on extending the agency's tobacco authority to cover additional tobacco products. Yet, not much is known about the hazards of these tobacco and potentially reduced exposure products (PREPs). Steam Stones are one alterative tobacco product where no quantitative information is available. These small pebble-like rocks contain no tobacco or nicotine and are coated in a viscous flavored fluid formulation consisting of glycerin, and are placed in a hookah head as an alternative to hookah tobacco. A total metal analysis with ICP–MS/MS was performed on the two originally marketed brands, Mya and Shiazo. The coatings of the stones underwent an initial hot water extraction for the purposes of determining the stones' metal composition for 26 metal targets. The toxic metals detected in both the Mya and Shiazo stones included trace levels of Cr, Ni, Cu, As, and Pb. This led to analyzing the toxic metals a smoker could potentially be exposed to during a 30 minute smoking session using both brands of steam stones and two different types of traditional smoldering charcoal. It was found that a smoker could inhale statistically similar quantities of Cr (between 12.2 ± 9.91 ng per smoking session to 1130 ± 776 ng per smoking session) and As (between 191 ± 30.1 ng per smoking session to 246 ± 101 ng per smoking session) when smoking one of four hookah head scenarios (scenario 1: Mya stones and Coco Nara charcoal, scenario 2: Mya stones and Fantasia charcoal, scenario 3: Shiazo stones and Coco Nara charcoal, and scenario 4: Shiazo stones and Fantasia charcoal). Although steam stones are marketed as free of nicotine, tar, carcinogens, and carbon monoxide, the use of traditional smoldering charcoal still exposes a user to these toxicants, including unacceptable amounts of harmful metals, such as Cr and As, despite the use of an alternative tobacco product. Notably, the use of electronic charcoal decreased the amount of toxic metals present in the smoke. Therefore, the smoke still contained relatively high levels of toxic metals, likely due to the use of traditional charcoal, which was previously quantified by ICP–MS/MS in our earlier paper [40].

To examine baseline characteristics and biochemically verified 1-, 4-, and 6-month tobacco quit rates among college students enrolled in a Quit and Win cessation trial, comparing those who concurrently smoke both hookah and cigarettes with those who deny hookah use.Analyses were conducted on data from 1217 college students enrolled in a Quit and Win tobacco cessation randomized clinical trial from 2010-2012. Multivariable logistic regression (MLR) analyses examined group differences in baseline characteristics and cotinine verified 30-day abstinence at 1, 4, and 6-month follow-up, adjusting for baseline covariates.Participants smoked 11.5(±8.1) cigarettes per day on 28.5(±3.8) days/month, and 22% smoked hookah in the past 30days. Hookah smokers (n=270) were more likely to be male (p0.0001), younger (p0.0001), report more binge drinking (p0.0001) and score higher on impulsivity (p0.001). MLR results indicate that hookah users, when compared to non-users, had a 36% decrease in odds of self-reported 30-day abstinence at 4-months (OR=0.64, 95% CI=0.45-0.93, p=0.02) and a 63% decrease in odds in biochemically verified continuous abstinence at 6-months (OR=0.37, CI=0.14-0.99, p=0.05).College cigarette smokers who concurrently use hookah display several health risk factors and demonstrate lower short and long-term tobacco abstinence rates.

Rationale Hookah smoking continues to be a popular form of tobacco use, especially among college students. Although hookahs are commonly used to smoke tobacco, anecdotal evidence suggests other substances, including herbal shisha, marijuana and hashish may be used. However, little is known about the variety of substances smoked in hookahs, or correlates associated with different substances smoked. Methods In fall 2010, 3447 students from 8 colleges in N.C. completed an online survey. Results 44% of students reported ever smoking tobacco from a hookah. Of those ever users, 90% reported smoking flavored tobacco in a hookah, 45% marijuana, 37% herbal (non-tobacco) shisha, and 18% hashish. Latent class analysis revealed two distinct classes. The most prevalent class (77%) primarily smoked flavored tobacco, with minimal use of herbal shisha and marijuana and virtually no use of hashish. The second class (23%) primarily smoked marijuana, hashish and flavored tobacco with moderate use of herbal shisha. Logistic regression analysis adjusting for clustering within schools revealed that males, illicit drug users, daily, nondaily and former cigarette smokers and those whose mothers had higher levels of education were significantly more likely to be in the second class compared to the first. Conclusions Rates of lifetime use of hookah were high in our sample of college students. While the majority of hookah users smoked tobacco in hookahs, they also smoked other substances, notably marijuana and herbal shisha. Prevention efforts should recognize that students are using hookahs to smoke a variety of substances.

Background Known most commonly in the U.S. as “hookah,” waterpipe tobacco smoking appears to be growing among college students. Despite beliefs that waterpipe use is safer than cigarette smoking, research to date (albeit limited) has found health risks of waterpipe smoking are similar to those associated with cigarette smoking, including lung cancer, respiratory illness, and periodontal disease. The goals of this study were to estimate the prevalence of use among a large, multi-institution sample of college students and identify correlates of waterpipe use, including other health-risk behaviors (i.e., cigarette smoking, alcohol, marijuana, and other illicit drug use) and availability of commercial waterpipe tobacco smoking venues. Methods A cross-sectional sample of 3770 college students from eight universities in North Carolina completed a web-based survey in fall 2008. Results Forty percent of the sample reported ever having smoked tobacco from a waterpipe, and 17% reported current (past 30-day) waterpipe tobacco smoking. Correlates associated with current waterpipe use included demographic factors (male gender, freshman class); other health-risk behaviors (daily and nondaily cigarette smoking, alcohol use, marijuana use, other illicit drug use); perceiving waterpipe tobacco smoking as less harmful than regular cigarettes; and having a commercial waterpipe venue near campus. Conclusions The results highlight the popularity of waterpipe tobacco smoking among college students and underscore the need for more research to assess the public health implications of this growing trend.

Waterpipe tobacco smoking is a centuries old practice, influenced by cultural tradition in Eastern Mediterranean countries, the Middle East, and parts of Asia. It historically has been an activity enjoyed primarily by men. In the past 2 decades, however, this method of tobacco smoking has increased in popularity in other parts of the world, including the USA. Growing interest in this form of smoking can be traced, in part, to the advent of a flavored tobacco, called maassel. The combination of flavoring agents and the paraphernalia itself used in the smoking process, along with its mystic appeal, novelty, affordability, and the social atmosphere in which smoking often occurs, has made waterpipe smoking attractive to women as well as men, cigarette smokers and nonsmokers alike, and particular groups, including persons of college age and younger adolescents. Although waterpipe smoking is perceived by its new generation of users to be less addictive and hazardous to health than cigarette smoking, researchers draw diametrically opposed conclusions. Research demonstrates that numerous toxic agents, including carcinogens, heavy metals, other particulate matter, and high levels of nicotine, are efficiently delivered through waterpipes. Moreover, sidestream smoke exposes others in the vicinity of waterpipe smokers to the risk of respiratory diseases and other conditions. In addition, persons sharing waterpipe mouthpieces may share infectious agents as well. Waterpipe tobacco smoking has been declared a public health problem by the World Health Organization and other authorities. Recognition of the deleterious effects of waterpipe smoking has led to initial attempts to expand regulatory control. Because waterpipe tobacco is not directly burned in the smoking process, many existing control measures do not apply. Public health authorities should monitor waterpipe tobacco use carefully. Finally, pediatricians and other healthcare providers should discourage experimentation and continued use among their adolescent patients.

In the past decade waterpipe (WP) smoking (a.k.a. hookah, shisha, and narghile) has been steadily spreading among the youth around the world. The allure of this tobacco use method for the youth can stem from its pleasant smooth smoke, social ambience and the perception of reduced harm. The material in this review is based on detailed Medline search for articles appearing especially in the past two years that are of relevance to WP epidemiology, health and addictive effects, and WP-related tobacco control policies. It shows that WP smoking is continuing to spread among the youth worldwide, and perhaps represents the second global tobacco epidemic since the cigarette. Available evidence suggests that the prevalence of current (past month) WP smoking range from 6 to 34% among Middle Eastern adolescents, 5%-17% among American adolescents, and that WP use is increasing globally. Studies on the health effects of WP smoking are limited by methodological quality, as well as by the novelty of WP epidemic relative to the long latency of important smoking-related health outcomes. Still, research indicates substantial WP harmful effects similar to those of cigarettes, as well as to the potential of providing a bridge to cigarette smoking or relapse. Developing effective interventions to curb WP use among the youth requires a detailed understanding of how dependence develops in WP users, and how it is shaped by WP's unique features such as the following; the predominantly intermittent use with prolonged sessions, preparation time, accessibility, potent sensory cues, and convivial experience of group use. It also requires assessing effective policy options such as factual and visible health warnings on all its parts, as well as youth access and indoor smoking restrictions. WP smoking is currently showing all signs of a burgeoning global epidemic with serious implications for public health and tobacco control worldwide. Investment in research and policy initiatives to understand and curb WP use needs to become a public health priority.

Background Waterpipe (hookah, shisha) tobacco smoking has spread worldwide. Many waterpipe smokers believe that, relative to cigarettes, waterpipes are associated with lower smoke toxicant levels and fewer health risks. For physicians to address these beliefs credibly, waterpipe use and cigarette smoking must be compared directly. Purpose The purpose of this study is to provide the first controlled, direct laboratory comparison of the toxicant exposure associated with waterpipe tobacco and cigarette smoking. Methods Participants (N=31; M=21.4 years, SD=2.3) reporting monthly waterpipe use (M=5.2 uses/month, SD=4.0) and weekly cigarette smoking (M=9.9 cigarettes/day, SD=6.4) completed a crossover study in which they each smoked a waterpipe for a maximum of 45 minutes, or a single cigarette. Outcome measures included expired-air carbon monoxide (CO) 5 minutes after session's end, and blood carboxyhemoglobin (COHb), plasma nicotine, heart rate, and puff topography. Data were collected in 2008–2009 and analyzed in 2009. Results On average, CO increased by 23.9 ppm for waterpipe use (SD=19.8) and 2.7 ppm for cigarette smoking (SD=1.8), while peak waterpipe COHb levels (M=3.9%, SD=2.5) were three times those observed for cigarette smoking (M=1.3%, SD=0.5; p's Conclusions Relative to cigarette smoking, waterpipe use is associated with greater CO, similar nicotine, and dramatically more smoke exposure. Physicians should consider advising their patients that waterpipe tobacco smoking exposes them to some of the same toxicants as cigarette smoking and therefore the two tobacco-smoking methods likely share some of the same health risks.

A smoking machine protocol and yields for "tar", nicotine, PAH, and CO are presented for the standard 171-puff steady periodic smoking regimen proposed by Shihadeh et al. [Shihadeh, A., Azar, S., Antonios, C., Haddad, A., 2004b. Towards a topographical model of narghile water-pipe cafe smoking: A pilot study in a high socioeconomic status neighborhood of Beirut, Lebanon. Pharmacology Biochemistry and Behavior 79(1), 75]. Results show that smokers are likely exposed to more "tar" and nicotine than previously thought, and that pyronsynthesized PAH are present in the "tar" despite the low temperatures characteristic of the tobacco in narghile smoking. With a smoking regimen consisting of 171 puffs each of 0.53l volume and 2.6s duration with a 17 s interpuff interval, the following results were obtained for a single smoking session of 10 g of mo'assel tobacco paste with 1.5 quick-lighting charcoal disks applied to the narghile head: 2.94 mg nicotine, 802 mg "tar", 145 mg CO, and relative to the smoke of a single cigarette, greater quantities of chrysene, phenanthrene, and fluoranthene. Anthracene and pyrene were also identified but not quantified. The results indicate that narghile smoke likely contains an abundance of several of the chemicals thought to be causal factors in the elevated incidence of cancer, cardiovascular disease and addiction in cigarette smokers.

skin vascular resistance by +44% (6.2 + 1 to 8.9 + 1 units, p1⁄40.001) with unchanged calf muscle vascular resistance (36.2 + 3 to 32.8 + 3 units, p1⁄4ns). In preliminary microneurographic studies, the differential regional vascular responses to hookah smoking were accompanied by increased sympathetic outflow to skin but not skeletal muscle. All cardiovascular parameters were unchanged in nine non-smoking time control studies. In conclusion, these data in overtly healthy young adult chronic hookah smokers document a striking discordance between perceived risk and the acute cardiovascular toxicity of hookah smoking. While perceived to be innocuous, each hookah smoking session constitutes a potent cardiovascular stimulant that is at least if not more potent than previously reported for cigarettes. Further studies are indicated to elucidate the underlying neural and vascular mechanisms, which overtime could accelerate development of hypertension.

s / Drug and Alcohol Dependence 146 (2015) e118–e201 e131 be presented from a population-based survey in California on the relationship of health status with attitudes toward and use of MM. Methods: The California Quality of Life Survey (2012–13) is a telephone follow-back survey of a subset of individuals (n=2267) who had participated in a statewide probability survey. The followback survey obtained information on health conditions, attitudes, and behaviors. Analyses examined socio-demographic characteristics and health conditions associated with attitudes toward and use of MM in the past year. All estimates were weighted to account for survey design. Results:Overall, 27.4%of the sampledisapprovedofMMuseand was higher among females; Asians and Hispanics; and individuals thatweremarried/cohabitating, had lower education andSES,were foreign-born,heterosexual (vs. sexualminority), in fair/poorhealth, andhadno illicit druguse in past year (all p

Introduction: Depression stands out as an important health issue that affects the entire family. Objectives: To assess the prevalence and level of depression and its relationship with autoantibodies, individual, environmental, laboratory and lifestyle parameters in miscarriage-patients. Aims: To evaluate the causes or effects of depression in recurrent miscarriage-patients. Methods: 50 variables containing sociodemographic data, healthrelated habits, depression, serum molecules and blood parameters were evaluated in recurrent miscarriage-patients and healthy women with natural childbirth. Results: Although no significant differences for 4 sociodemographic and 18 health-related lifestyle parameters were found between patients and controls, depression score and its prevalence was higher in patients than controls. Depression scores were higher in miscarriage-patients (ranging 3–36, mean = 11.92±1.37) than controls (ranging 0–8, mean = 3.05±0.63) which 80.96% of them had no or mild, 2.38% mild-moderate, 4.76% moderate and 11.9% severe depression. There was also a significant association between antidouble-stranded-DNA-antibody (anti-dsDNA) or rheumatoid-factor (RF) level and depression in miscarriage-patients. Interestingly, depression score was inversely correlated with the level of solubleleptin-receptor (sLeptinR) and soluble-glyeoprotein-130 (sgp130) after controlling for covariates in patient groups. Depression of miscarriage-patients was correlated with hookah consumption rate. Surprising that, the association between abortion histories and depression in miscarriage-patients become not significant after controlling for age. Conclusions: Depression score and its prevalence are higher in miscarriage-patients than controls. The depression levels are correlated with certain autoantibodies such as anti-dsDNA or some habits like hookah smoking in miscarriage-patients. Inverse association between depression and some soluble molecules like sgp130 or sLeptinR in recurrent miscarriage-patients also remained to be elucidated.

Introduction: Depression stands out as an important health issue that affects the entire family. Objectives: To assess the prevalence and level of depression and its relationship with autoantibodies, individual, environmental, laboratory and lifestyle parameters in miscarriage-patients. Aims: To evaluate the causes or effects of depression in recurrent miscarriage-patients. Methods: 50 variables containing sociodemographic data, healthrelated habits, depression, serum molecules and blood parameters were evaluated in recurrent miscarriage-patients and healthy women with natural childbirth. Results: Although no significant differences for 4 sociodemographic and 18 health-related lifestyle parameters were found between patients and controls, depression score and its prevalence was higher in patients than controls. Depression scores were higher in miscarriage-patients (ranging 3–36, mean = 11.92±1.37) than controls (ranging 0–8, mean = 3.05±0.63) which 80.96% of them had no or mild, 2.38% mild-moderate, 4.76% moderate and 11.9% severe depression. There was also a significant association between antidouble-stranded-DNA-antibody (anti-dsDNA) or rheumatoid-factor (RF) level and depression in miscarriage-patients. Interestingly, depression score was inversely correlated with the level of solubleleptin-receptor (sLeptinR) and soluble-glyeoprotein-130 (sgp130) after controlling for covariates in patient groups. Depression of miscarriage-patients was correlated with hookah consumption rate. Surprising that, the association between abortion histories and depression in miscarriage-patients become not significant after controlling for age. Conclusions: Depression score and its prevalence are higher in miscarriage-patients than controls. The depression levels are correlated with certain autoantibodies such as anti-dsDNA or some habits like hookah smoking in miscarriage-patients. Inverse association between depression and some soluble molecules like sgp130 or sLeptinR in recurrent miscarriage-patients also remained to be elucidated.

I was very surprised by the admonishing tone of Dr Maziak’s criticism of Carroll et al. study in Issue 5 of Vol. 32. After careful evaluation, I found the latter article excellent all the more that it involved a large sample, made a clear division of groups, and was the first to report the prevalence of hookah (shisha, narghile) smoking in an Australian population. ‘Public health’ does not belong to any group or individual in particular. It is public and should remain a public concern as its names clearly show, even when the matter deals with such a hot topic as tobacco and ‘waterpipe’ smoking. It is sad to see how Carroll et al. were led to justify their ‘unexpected’ finding by adding: “this may not be reflected in other regional or population settings”. They did not have to, especially because their findings are in agreement with observations in many other parts of the world and, not the least, with early anthropological observations in Asia, Africa and Europe. The ‘gateway’ hypothesis is irrelevant as hookah does not seem to differ from smokeless tobacco of the Swedish SNUS type. Experts in this field state: “the major ‘gateway’ to adult cigarette smoking is a cigarette itself ” and that “a high risk child would be better off using SNUS than cigarettes, if the child is determined to use tobacco”. Concerning health aspects, it must be understood 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 4,700 substances that have been identified so far in cigarette smoke. Logically, this should have made research easier. Unfortunately, for seven years now, there has been nothing but a growing world confusion in this respect. This global disorder is firstly due to the abuse of smoking machines supposed to model hookah smoking in its natural environment, i.e. as it is performed by humans from Sydney to Beirut. Then, there is the question of the vocabulary because using ‘waterpipe’ – instead of the natural words (three main ones: hookah, shisha, narghile) used by peoples in their daily language and to be found in all dictionaries of the world – has implied the blind endorsement of a scientific nominalism with tremendous consequences on research. By using an imposed neologism outside a given and limited geographical area, their users just draw a parallel between devices known to produce fumes with very different chemical compositions and corresponding smoking patterns. For instance, a shisha (in which the charcoal and smoking mixture are separated by a tin foil and in which temperatures scarcely go in excess of 150°C) used in New Zealand is completely different from a Chinese water pipe (involving a tiny amount of tobacco and no charcoal) or an Egyptian goza (direct contact between the charcoal and the mixture in which temperatures are higher). Practically, the following statement “The Chinese water pipe [in 2 words] is smaller than the Iranian narghile” is true from a logics viewpoint. “Iran has two main water pipes: Narghile and Qalyan” and “Mada‘a is the national Yemeni water pipe even though there are other types” are also true statements. However, statements as “Waterpipe is [this or that]” or “Waterpipe use causes [this or that] disease]”, without any given information about the geometry of the pipe, the nature of the smoking preparation (tobacco, no tobacco, molasses or not, charcoal or not, etc.) are false from the same scientific viewpoint. As for the strategy to adopt ahead of a predicted epidemic, it is amazing to hear from ‘waterpipe’ experts that patterns may change in the near future. The unrealised fact is that one great anthropological change has already occurred and been described in detail: i.e. the passage from tobacco (and molasses) directly heated by charcoal (tumbak, jurâk) to a lighter form (moassel, flavoured) in which the mixture is separated from the heating source. Public health officials have been led astray by experts in a hurry. Finally, did we need eight years of international research and half hundred of ‘waterpipe’ studies to establish that “the waterpipe is mainly an intermittent tobacco use method”, or was this fact already established by four centuries of literature, including early scientific studies, and not to mention common sense? What are scientific reviews made for?