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Narghile (hookah, shisha) tobacco smoking: expect the unexpected everywhere and not only in Syria
International Journal of Infectious Diseases 14S (2010) e353–e354
Contents lists available at ScienceDirect
International Journal of Infectious Diseases journal homepage: www.elsevier.com/locate/ijid
Letter to the Editor Narghile (hookah, shisha) tobacco smoking: expect the unexpected everywhere and not only in Syria In their Letter, Al-Faham et al. warn that Syria is a country in which tourists can ‘‘expect the unexpected’’ because of the social (cafes) and health (infections) consequences of the widespread use of an artifact called narghile (shisha, hookah).1 In fact, this material object and its use are actually held responsible for a worldwide epidemic, which, it is true, draws the interest of tourists, however not only in Syria, but also in many other countries, such as Lebanon, Jordan, Egypt, Libya, Tunisia, etc.2 One of the objective reasons behind the world upsurge in narghile smoking is a chasse´croise´ (criss-crossing) of global tourism and migration flows that particularly intensified in the nineties.3 As for ‘‘the ambiance of water-pipe cafe´s’’, it is not a new phenomenon either. Westerners who, in the past centuries, visited or lived in the Middle East region – such as Pierre Loti (Turkey) and Alphonse De Lamartine (Syria and Lebanon), not to mention many orientalist painters – had actually been enthralled by such an exotic and colorful atmosphere. Their writings and paintings show that they understood, from an anthropological viewpoint, that the very reason for this special ambiance was the narghile itself. In the modern era, a prestigious Lebanese lung specialist warned recently, from the very Middle East wherefrom the world narghile epidemic started two decades ago, that such a habit has been, for centuries, an actual ‘‘art de vivre’’, i.e. an art of living well.4 Fortunately, this tobacco habit has not raised any major health problem for centuries.2 However, because of changes in its use, it can pose new problems that have not been soundly analyzed so far.2,3 For instance, one cannot squarely state that narghile is an ‘‘unexpected means of transmission of infections’’.1 Narghile, and the water-pipe in general,5 was identified early on as a means of potential transmission of pathogenic germs, tuberculosis in particular, because of the social habit of passing around the suction hose from mouth to mouth. Fortunately, individual aseptic nozzles have been commonly used and on a large scale in cafes and restaurants around the world,2 as in those described by Al-Faham et al.1 However, errors and misrepresentations about communicable diseases are unfortunately very frequent. In a paper published in The Lancet Infectious Diseases, a researcher who relied exclusively on the World Health Organization report on ‘waterpipe’ smoking, replicated the errors found therein about tuberculosis.6,7 More generally, and as repeatedly recalled in the past, the association of hookah smoking with potential diseases is not clearly established and confusion has been frequent because of a non-rigorous methodology, for example: simultaneous use of other products such as cigarettes, qat, bidis, etc.; strongly neglected hygiene; unspecified remote and recent smoking
habits, etc. The case of aspergillosis,8 cited by Maziak et al. in the supposedly peer-reviewed ‘waterpipe’ mainstream literature9 and uncritically referred to by Al-Faham et al.,1 is interesting because the patient described in the corresponding study did not change the water of his narghile for weeks, whereas it is a common practice to do so at the end of each session, i.e., one to several times every day. Finally, the authors cite another Syrian study in which medical students were asked about their use of cigarettes and narghile.1,10 This question was as unexpected as irrelevant, because while a Syrian medical student might, until recently, have smoked cigarettes in corridors and lecture halls of the university, puffing at the narghile in such places would be rather cumbersome and unusual. Indeed, for this purpose, Syrian medical students patronize traditional coffee houses outside the campus. Therefore, the cited study contained bias partly due to the so-called ‘standardized ‘waterpipe’ questionnaire’ on which it relied. It is also noteworthy that ‘waterpipe’ (one word, singular) is nonexistent in Arabic and many other languages (Turkish, Persian, Urdu, Hindi, Hebrew, etc.), including English and other Latin-based languages. The use of this neologism, on which there has been absolutely no scientific consensus, has actually led to the endorsement of a scientific nominalism which, from time to time, leads research to a dead end.11 Fortunately, Al-Faham et al. used ‘narghile’.1 However, they should be aware of this problem, which is not a mere linguistic issue as some ‘‘tobacco naı¨ve’’ researchers unfortunately believe. Conflict of interest No conflict of interest to declare. References 1. Al-Faham Z, Takriti F, Habboub G, Jawaid A. Travel to Syria: expect the unexpected. Int J Infect Dis 2009;13:e326. 2. Chaouachi K. The medical consequences of narghile (hookah, shisha) use in the world. Rev Epidemiol Sante Publique 2007;55:165–70. 3. Chaouachi K. Hookah (shisha, narghile) smoking and environmental tobacco smoke (ETS). A critical review of the relevant literature and the public health consequences. Int J Environ Res Public Health 2009;6:798–843. 4. Waked M. Le narguile´: quand la fume´e se dissipe [Narghile: beyond the cloudy smoke]. La Lettre du Pneumologue (Edimark) 2006;9:177–9. 5. Munckhof WJ, Konstantinos A, Wamsley M, Mortlock M, Gilpin C. A cluster of tuberculosis associated with use of a marijuana water pipe. Int J Tuberc Lung Dis 2003;7:860–5. 6. Meleigy M. Waterpipe and communicable diseases link, says WHO. Lancet Infect Dis 2007;7:448. 7. Chaouachi K. Hookah (narghile, shisha) smoking and communicable diseases. Tabaccologia 2008;1:47. 8. Szyper-Kravitz M, Lang R, Manor Y, Lahav M. Early invasive pulmonary aspergillosis in a leukemia patient linked to Aspergillus contaminated marijuana smoking. Leuk Lymphoma 2001;42:1433–7.
1201-9712/$36.00 – see front matter ß 2009 International Society for Infectious Diseases. Published by Elsevier Ltd. All rights reserved. doi:10.1016/j.ijid.2009.08.016
e354
Letter to the Editor / International Journal of Infectious Diseases 14S (2010) e353–e354
9. Maziak W, Ward KD, Afifi Soweid RA, Eissenberg T. Tobacco smoking using a waterpipe: a re-emerging strain in a global epidemic. Tobacco Control 2004;13:327–33. 10. Almerie MQ, Matar HE, Salam M, Morad A, Abdulaal M, Koudsi A, et al. Cigarettes and waterpipe smoking among medical students in Syria: a crosssectional study. Int J Tuberc Lung Dis 2008;12:1085–91. 11. Chaouachi K. Micronuclei and shisha/goza smoking in Egypt. Mutat Res 2009;675:81–2.
*Tel.: +33 1 49289860 E-mail address: [email protected] (K. Chaouachi) Corresponding Editor: William Cameron, Ottawa, Canada 24 April 2009
Kamal Chaouachi* DIU Tabacologie, Universite Paris XI, 18, Alle´e des Petits Bois, Versailles, France
Contents lists available at ScienceDirect
International Journal of Infectious Diseases journal homepage: www.elsevier.com/locate/ijid
Letter to the Editor Narghile (hookah, shisha) tobacco smoking: expect the unexpected everywhere and not only in Syria In their Letter, Al-Faham et al. warn that Syria is a country in which tourists can ‘‘expect the unexpected’’ because of the social (cafes) and health (infections) consequences of the widespread use of an artifact called narghile (shisha, hookah).1 In fact, this material object and its use are actually held responsible for a worldwide epidemic, which, it is true, draws the interest of tourists, however not only in Syria, but also in many other countries, such as Lebanon, Jordan, Egypt, Libya, Tunisia, etc.2 One of the objective reasons behind the world upsurge in narghile smoking is a chasse´croise´ (criss-crossing) of global tourism and migration flows that particularly intensified in the nineties.3 As for ‘‘the ambiance of water-pipe cafe´s’’, it is not a new phenomenon either. Westerners who, in the past centuries, visited or lived in the Middle East region – such as Pierre Loti (Turkey) and Alphonse De Lamartine (Syria and Lebanon), not to mention many orientalist painters – had actually been enthralled by such an exotic and colorful atmosphere. Their writings and paintings show that they understood, from an anthropological viewpoint, that the very reason for this special ambiance was the narghile itself. In the modern era, a prestigious Lebanese lung specialist warned recently, from the very Middle East wherefrom the world narghile epidemic started two decades ago, that such a habit has been, for centuries, an actual ‘‘art de vivre’’, i.e. an art of living well.4 Fortunately, this tobacco habit has not raised any major health problem for centuries.2 However, because of changes in its use, it can pose new problems that have not been soundly analyzed so far.2,3 For instance, one cannot squarely state that narghile is an ‘‘unexpected means of transmission of infections’’.1 Narghile, and the water-pipe in general,5 was identified early on as a means of potential transmission of pathogenic germs, tuberculosis in particular, because of the social habit of passing around the suction hose from mouth to mouth. Fortunately, individual aseptic nozzles have been commonly used and on a large scale in cafes and restaurants around the world,2 as in those described by Al-Faham et al.1 However, errors and misrepresentations about communicable diseases are unfortunately very frequent. In a paper published in The Lancet Infectious Diseases, a researcher who relied exclusively on the World Health Organization report on ‘waterpipe’ smoking, replicated the errors found therein about tuberculosis.6,7 More generally, and as repeatedly recalled in the past, the association of hookah smoking with potential diseases is not clearly established and confusion has been frequent because of a non-rigorous methodology, for example: simultaneous use of other products such as cigarettes, qat, bidis, etc.; strongly neglected hygiene; unspecified remote and recent smoking
habits, etc. The case of aspergillosis,8 cited by Maziak et al. in the supposedly peer-reviewed ‘waterpipe’ mainstream literature9 and uncritically referred to by Al-Faham et al.,1 is interesting because the patient described in the corresponding study did not change the water of his narghile for weeks, whereas it is a common practice to do so at the end of each session, i.e., one to several times every day. Finally, the authors cite another Syrian study in which medical students were asked about their use of cigarettes and narghile.1,10 This question was as unexpected as irrelevant, because while a Syrian medical student might, until recently, have smoked cigarettes in corridors and lecture halls of the university, puffing at the narghile in such places would be rather cumbersome and unusual. Indeed, for this purpose, Syrian medical students patronize traditional coffee houses outside the campus. Therefore, the cited study contained bias partly due to the so-called ‘standardized ‘waterpipe’ questionnaire’ on which it relied. It is also noteworthy that ‘waterpipe’ (one word, singular) is nonexistent in Arabic and many other languages (Turkish, Persian, Urdu, Hindi, Hebrew, etc.), including English and other Latin-based languages. The use of this neologism, on which there has been absolutely no scientific consensus, has actually led to the endorsement of a scientific nominalism which, from time to time, leads research to a dead end.11 Fortunately, Al-Faham et al. used ‘narghile’.1 However, they should be aware of this problem, which is not a mere linguistic issue as some ‘‘tobacco naı¨ve’’ researchers unfortunately believe. Conflict of interest No conflict of interest to declare. References 1. Al-Faham Z, Takriti F, Habboub G, Jawaid A. Travel to Syria: expect the unexpected. Int J Infect Dis 2009;13:e326. 2. Chaouachi K. The medical consequences of narghile (hookah, shisha) use in the world. Rev Epidemiol Sante Publique 2007;55:165–70. 3. Chaouachi K. Hookah (shisha, narghile) smoking and environmental tobacco smoke (ETS). A critical review of the relevant literature and the public health consequences. Int J Environ Res Public Health 2009;6:798–843. 4. Waked M. Le narguile´: quand la fume´e se dissipe [Narghile: beyond the cloudy smoke]. La Lettre du Pneumologue (Edimark) 2006;9:177–9. 5. Munckhof WJ, Konstantinos A, Wamsley M, Mortlock M, Gilpin C. A cluster of tuberculosis associated with use of a marijuana water pipe. Int J Tuberc Lung Dis 2003;7:860–5. 6. Meleigy M. Waterpipe and communicable diseases link, says WHO. Lancet Infect Dis 2007;7:448. 7. Chaouachi K. Hookah (narghile, shisha) smoking and communicable diseases. Tabaccologia 2008;1:47. 8. Szyper-Kravitz M, Lang R, Manor Y, Lahav M. Early invasive pulmonary aspergillosis in a leukemia patient linked to Aspergillus contaminated marijuana smoking. Leuk Lymphoma 2001;42:1433–7.
1201-9712/$36.00 – see front matter ß 2009 International Society for Infectious Diseases. Published by Elsevier Ltd. All rights reserved. doi:10.1016/j.ijid.2009.08.016
e354
Letter to the Editor / International Journal of Infectious Diseases 14S (2010) e353–e354
9. Maziak W, Ward KD, Afifi Soweid RA, Eissenberg T. Tobacco smoking using a waterpipe: a re-emerging strain in a global epidemic. Tobacco Control 2004;13:327–33. 10. Almerie MQ, Matar HE, Salam M, Morad A, Abdulaal M, Koudsi A, et al. Cigarettes and waterpipe smoking among medical students in Syria: a crosssectional study. Int J Tuberc Lung Dis 2008;12:1085–91. 11. Chaouachi K. Micronuclei and shisha/goza smoking in Egypt. Mutat Res 2009;675:81–2.
*Tel.: +33 1 49289860 E-mail address: [email protected] (K. Chaouachi) Corresponding Editor: William Cameron, Ottawa, Canada 24 April 2009
Kamal Chaouachi* DIU Tabacologie, Universite Paris XI, 18, Alle´e des Petits Bois, Versailles, France