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• Further comments on "Water-pipe smoking and dental stains – Adding fuel to the controversy?"
  FOUAD A. AL- BELASY
  Published on: 13 May 2016
• Waterpipe Smoking and Dental Stains-Adding fuel to the controversy?”
  Sebastian Thomas
  Published on: 13 May 2016
• Failure to declare competing interest
  Simon Chapman
  Published on: 13 May 2016
• Serious Errrors in this Study
  Kamal Chaouachi
  Published on: 13 May 2016

• Published on: 13 May 2016

  Further comments on "Water-pipe smoking and dental stains – Adding fuel to the controversy?"

  • FOUAD A. AL- BELASY, Professor of Oral and Maxillofacial Surgery, Associate Dean for Education and Students Affairs

  Dear editor,

  In reference to the e-letter published on July, 24, 2007, entitled "Water-pipe smoking and dental stains – Adding fuel to the controversy?" and authored by Sebastian et al., I'd like to share with comments on the following:

  1- The generalizations that "Shisha (Water-pipe) smokers did not develop any stains while Cigarette smokers had grade 3 dental stains at the end of 100 days" and "Coal...

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  Dear editor,

  In reference to the e-letter published on July, 24, 2007, entitled "Water-pipe smoking and dental stains – Adding fuel to the controversy?" and authored by Sebastian et al., I'd like to share with comments on the following:

  1- The generalizations that "Shisha (Water-pipe) smokers did not develop any stains while Cigarette smokers had grade 3 dental stains at the end of 100 days" and "Coal tar combustion does not happen in water- pipe smoking, since no stains formed in 100 days" need further scrutiny. These generalizations (that describe how some aspect of a phenomenon behaves under stated circumstances) are based on a very small number of study subjects (10 in each group) and a too short period of evaluation (100 days). My observation is that dental staining occurs in both Shisha and cigarette smokers even with enthusiastic measures of oral hygiene. A crucial factor to consider, however, is that cigarettes can be smoked at any point of the 24 hours of the day, while smoking Shisha is not. This entails different environmental factors during cigarette smoking.

  2- The inference that "tar produced by a water-pipe may differ from that produced by a cigarette was interpreted on the basis that tobacco in a water-pipe is not burnt, but heated". However, tobacco undergoes burning during both Shisha (water-pipe) and cigarette smoking. The difference is that tobacco in a cigarette is drier than in Shisha. While tobacco in a cigarette can be burnt negatively without inhalation once the cigarette is lit, it requires continuous inhalation during Shisha smoking. However, if a cigarette with a damp tobacco is lit and left without inhalation no further burning will occur and the cigarette will be in need of lighting it again. Furthermore, examination of tobacco after Shisha smoking will be of 2 types; completely (ash type) and partly (mixed type) burnt tobacco.

  3. No safety does exist for any type of smoking and no controversy should exist for Shisha (water-pipe) smoking.

  Fouad Al-Belasy Professor of Oral and Maxillofacial Surgery, Associate Dean for Education and Students Affairs, Faculty of Dentistry, Mansoura University, EGYPT

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  Conflict of Interest:
  None declared.

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• Published on: 13 May 2016

  Waterpipe Smoking and Dental Stains-Adding fuel to the controversy?”

  • Sebastian Thomas, Lecturer
  • Other Contributors:
    • Bashir K.Hush

  A controversy has been raging regarding the relative safety of waterpipe smoking . To investigate the claims of few university students who smoked waterpipe that waterpipe smoke (WPS) does not cause dental stains, we compared cigarette and waterpipe smokers.

  Two groups each of 10 subjects were selected .One group comprising of only water pipe smokers (including 9 waterpipe cafe caretakers), the other made of on...

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  A controversy has been raging regarding the relative safety of waterpipe smoking . To investigate the claims of few university students who smoked waterpipe that waterpipe smoke (WPS) does not cause dental stains, we compared cigarette and waterpipe smokers.

  Two groups each of 10 subjects were selected .One group comprising of only water pipe smokers (including 9 waterpipe cafe caretakers), the other made of only cigarette smokers who smoked 20-30 cigarettes daily. All the subjects brushed once daily, using tooth paste. Thorough oral prophylaxis was done, subjects were asked not to indulge in any means of smoking other than what specified. Dental stains were evaluated every 10th day for 100 days.

  Dental Stain Grading: Only lingual aspects of lower anterior teeth were evaluated.

  Grade 1- Stain present on the cervical (lower) 1/3rd

  Grade 2- Stain present on the cervical and middle 1/3rds.

  Grade 3- Stain present on the cervical, middle and incisal 1/3rds.

  It was observed that waterpipe smokers did not develop any dental stains while cigarette smokers had Grade 3 dental stains at the end of 100 days.

  Staining of teeth results primarily from coal tar combustion products.[1] One may assume that coal tar combustion does not happen in waterpipe smoking , since no stains formed in 100 days. In fact, the smoke from a single waterpipe use contains approximately the same amount of tar as 20 cigarettes.[2] However, the tar produced by a waterpipe may differ from that produced by a cigarette, because tobacco in a waterpipe is not burnt, but heated.[3] Also, the smoke after passing through the water bowl loses heat almost completely before reaching the oral cavity.

  High incidence of pre cancerous oral lesions has been reported due to reverse smoking, possibly due to increased intra oral temperature and different combustion products.[4] In reverse smoking the chemical action of tobacco is supplemented by the irritant effect of heat. Where as in WPS, the heat factor is negated. Temperature may be positively related to tar related tumorigenicity and mutagenicity.[2,3]

  This should not let us underestimate the potential ill effects of WPS. WPS contains charcoal-combustion products as well. The water does absorb some of the nicotine.[5] Reduced concentration of nicotine in the WPS may result in smokers inhaling higher amounts of smoke until they get enough nicotine to satisfy their need and addiction;[6] and thus exposing themselves to higher levels of cancer-causing chemicals and hazardous gases such as carbon monoxide than if none of the nicotine was absorbed by the water.[7]

  References

  1. Carranza FA, Newman MG. Clinical Periodontology, 8th ed. W.B. Saunders Company: 1996:158.

  2. Shihadeh A. Investigation of mainstream smoke aerosol of the argileh water pipe. Food Chem Toxicol. 2003;41:143-152.

  3. Maziak W, Ward KD, Afifi Soweid RA, et al. Tobacco smoking using a waterpipe: a re-emerging strain in a global epidemic. Tob Control. 2004;13:327-333.

  4. Lynch MA, Brightman VJ, Greenberg MS. Burket’s Oral Medicine, Diagnosis and Treatment,9th ed.J.B.Lippincott.1994:93.

  5. Shafagoj YA, Mohammed FI, Hadidi KA. Hubble-bubble (water pipe) smoking: levels of nicotine and cotinine in plasma, saliva and urine. Int J Clin Pharmacol Ther. 2002; 40:249-255.

  6. National Cancer Institute. Risks associated with smoking cigarettes with low machine-measured yields of tar and nicotine. Smoking and Tobacco Control Monograph No.13.Bethesda MD, United States Department of Health and Human Services ,Public Health Service ,National Institutes of Health ,National Cancer Institute.2001.

  7. Knishkowy B, Amitai Y. Water-pipe (narghile) smoking: An emerging health risk behavior. Pediatrics. 2005;116:113-119.

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  Conflict of Interest:
  None declared.

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• Published on: 13 May 2016

  Failure to declare competing interest

  • Simon Chapman, Editor

  On March 15 2007, my attention was drawn to a patent for a tobacco smoking device, filed with the U.S. Patent and Trademark Office (USPTO) for a "Hookah with simplified lighting" on June 9 2005. One of the authors of the device being patented was Kamal Chaouachi, who on December 2 2004, had a rapid response published in Tobacco Control [1] which was critical of a paper by Masiak et al [2]. The submission process for rapid...

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  On March 15 2007, my attention was drawn to a patent for a tobacco smoking device, filed with the U.S. Patent and Trademark Office (USPTO) for a "Hookah with simplified lighting" on June 9 2005. One of the authors of the device being patented was Kamal Chaouachi, who on December 2 2004, had a rapid response published in Tobacco Control [1] which was critical of a paper by Masiak et al [2]. The submission process for rapid responses asks authors to “Please declare any competing interests”. I noted that Dr Chaouachi’s letter contained no competing interest statement and so wrote to him requesting that he submit a further rapid response which would clarify his competing interest.

  He duly submitted two rapid responses. The first, which I have not published but retained, simply said “no competing interests”. I replied that this brief response was unacceptable and that in the circumstances of the revelation about his ostensible interest in the smoking device, he should elaborate in a further rapid response.

  In the second response Dr Chaouachi stated that he had signed away his rights “in the presence of a State Attorney” to his tobacco smoking invention patent on June 15 2005, some six days after the US patent was filed. Dr Chaouachi reiterated that “I had no competing interest at the time my Letter to the Editor entitled 'Serious Effors in this Study" was sent to the Tobacco Control Journal.”

  This last statement, in fact, is false. I am in possession of a report from the French patent office (Bulletin Officiel De La Propriete Industrielle Brevets D'Invention). At page 18 a patent in the names of Billard, Chaouachi (Kamal), and De La Giraudiere is described. The patent number is 04 06287, the company filing the patent is "Shishamania International", the title of the patent is "NARGUILLE A ALLUMAGE SIMPLIFIE". The date of filing is June 10 2004.

  Thus, the US patent, filed at the US PTO on June 9, 2005, was first filed in France on June 10, 2004. Dr Chaouachi’s e-letter was submitted on December 2 2004. Therefore, the e-letter was submitted after the French patent was filed, and before the date on which he reports that he relinquished his rights to the patent.

  In further correspondence during March 17, I confronted Dr Chaouachi with the fact that his device had been registered with the French patent authorities in June 2004 and that therefore he had made a false statement in his declaration of no competing interests. He replied “This is not "false statement" (!). … The French patent was filed at the date you said. You are probably right as I cannot say myself so far when it was. I have been informed of procedure. This is all.”

  In summary, at the date Dr Chaouachi submitted his rapid response, he had a commercial interest in the subject of that submission. He did not declare this interest. When later given the opportunity to do so, he maintained that he had no competing interest at the time of writing his rapid response. He did not voluntarily declare that the patent had in fact been filed in France in June 2004.

  In such circumstances, it is Tobacco Control’s policy to inform offending authors’ institutions of such conduct. Dr Chaouachi would appear to not be currently working for any institution. Tobacco Control is unwilling to accept any further submissions from Dr Chaouachi.

  Simon Chapman Editor

  1. Chaouachi K. Serious Errors in this Study. http://tc.bmj.com/cgi/eletters/13/4/327 rapid response

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

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  Conflict of Interest:
  None declared.

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• Published on: 13 May 2016

  Serious Errrors in this Study

  • Kamal Chaouachi, Researcher
  • Other Contributors:
    • N/A

  Dear Editor

  I have analysed the US-funded review and I want to share some of my findings. I am afraid there are serious errors in this document and I will quote only two of them to give an idea of their scope.

  ERRORS. “Waterpipe use likely increases the risk of bronchogenic carcinoma [68] as well as lung [16,20,69] oral,[8] and bladder [21,70] cancers.”

  I will not discuss each of all the cited references bec...

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  Dear Editor

  I have analysed the US-funded review and I want to share some of my findings. I am afraid there are serious errors in this document and I will quote only two of them to give an idea of their scope.

  ERRORS. “Waterpipe use likely increases the risk of bronchogenic carcinoma [68] as well as lung [16,20,69] oral,[8] and bladder [21,70] cancers.”

  I will not discuss each of all the cited references because most of the volunteers were simultaneous or ex-users of different (tobacco) products. I will only focus on references 69 and 16. Ref 69 is : Rakower J, Fatal B. Study of Narghile Smoking in Relation to Cancer of the Lung. Br J Cancer. 1962 Mar; 16:1-6.

  In blatant opposition to the above interpretation, the two cited researchers clearly said from the outset how they surprisingly noticed that “there [was] an eightfold difference between the lowest lung cancer mortality rate for the immigrants [Jews] from Yemen [a majority of them being hookah smokers] and the highest for the immigrants from Europe [50% were smokers and most of them were cigarette users].” This strange fact led them to analyse the tar filtering properties of narghile (results: 84mg for 10g of tobacco ; 161mg without water in the vase). As it was not enough to explain the low rates they observed, they discussed, among other matters, the influence of inhalation patterns and the question of temperature.

  Many other references not cited in this review tend to show that hookah actually reduces the risk of lung cancer. Should we also add that Rakower and his colleague were talking about was “tumbâk” which contains much more nicotine than the one (tobamel) which is gradually swamping the world? Or that the same hookah used by Yemenis (mada’a) is usually topped with tons of charcoal?

  The other cited reference (#16) is Lubin JH et al. (Quantitative evaluation of the radon and lung cancer association in a case control study of Chinese tin miners. Cancer Res 1990; 50:174–80). But we are not told that the same Lubin, only two years later, concluded another study by : [water] “pipe smoking may be less deleterious than cigarette smoking. The reasons for this are unclear, but may be due to the filtration action of the water bath or to less vigorous inhalation of pipe smoke”. (Lubin JH, Li JY, Xuan XZ, Cai SK, Luo; Yang QS, Wang JZ, Yang L; Blot WJ. Risk of lung cancer among cigarette and pipe smokers in southern China. Int. J. of Cancer 1992; 51 (3)3: 390-5.)

  Strangely enough, neither the last reference nor another chief one, Hazelton (*), are cited.

  METHODOLOGY. A fair number of the cited references relies on a previous, also US-funded, Egypt-based review (**) which is actually a mix of Medline abstracts and summaries of local documents. The authors of the last report pretend that “many of the studies on these subjects [i.e. hookah use] are merely anecdotal or lack the necessary rigorous study design or the power needed to be certain of the results.” (Radwan)

  Rigour, that’s the word. This new “review” tells us about its one-year “precursor” that it “focused on Egyptian waterpipe research”. I am sorry to say that this is a wrong statement because the scope of the latter was going far beyond Egypt and was as wide as the new one. This has to be said from an ethical point of view: the modest researchers of the American-Egyptian team (ESPRI Centre) should deserve our respect for their work and its scope. Besides, it must be clear that both their document and the new one, we are talking about now, contain errors, the latter however to a greater extent.

  This new review also emphasises the fact that it is “comprehensive” and “critical”. However, let’s point out that key references (*) are strangely absent in this document not to mention the best introduction to the issue : a 420 page multi-disciplinary doctoral thesis the abstract of which has been widely advertised over the past years among the tobacco control community and Globalink members. This work contains the 4 first reviews in sociology, anthropology, history and tobaccology (health and pharmacological aspects) concerning hookah/narghile use.

  Indeed, was Wolfram the relevant reference (number 3) to support the given figure of people using hookah in the world or the other fact that its use is multi-century ? Wolfram is the right specialist for the platelet function but did the authors really know where he got that data from ? Let us tell them: indirectly from the a.m. thesis.

  Consequently, it would have been more respectful and relevant to quote the existence of that document. As for the “criticical” side, the reader of that document will be informed of what happened to an unlucky fellow who used a hookah: aspergillosis… without knowing that the poor man did not change the water of his hookah for weeks… Effectively, the authors did not deem it necessary to bring out such a “detail”. For those who don’t know how a hookah is served, let us make it clear here that the water inside the vase is changed at the end of each session.

  PREVENTION. This is, in my opinion, the most important and pressing issue and I regret that no practical orientation is given whereas so many ideas could be put forward instead of untiringly awaiting sound scientific evidence-based results from humans or from God.

  CONCLUSION. Finally, since this document has been advertised and will probably be “indexed” under Mother Medline, the loop is looped and the boucle est bouclée, as French would say. Consequently, I urge everybody interested in this topic to access that document and personally check what I have been saying through these lines. I am ready to provide any colleague with a commented list of all other serious errors (about nitrosamines, lead, etc.) I have picked up in the document and I am ready to defend my position in any public debate.

  Unlike before, I now sometimes ask myself : what is the reason behind such a stakhanovist production of papers on hookah the outcome of which only leads to more and more confusion (“bizid ettin bellé”, would we say in Arabic) ?

  - Do we need quantity or elementary common sense-based quality ? - Do we need ideology (we regret that the authors also attack smokeless tobacco…), boycott and blind unprofitable competition or international multidisciplinary co-operation to face the new challenge the worldwide spread of hookah use represents?

  I only hope all this hubble-bubble-toil-and-trouble is not a race for funds in this merchant world ? You see, I am very perplexed these days.

  Thank you for your attention.

  Kamal Chaouachi, author of:

  - DOCTORAL THESIS: « Le narguilé : analyse socio-anthropologique. Culture, convivialité, histoire et tabacologie d’un mode d’usage populaire du tabac », Université Paris X, 2000, 420 pages. (English free translation): “Narghile (hookah): a Socio-Anthropological Analysis. Culture, Conviviality, History and Tobaccology of a Popular Tobacco Use Mode”, 420 pages. This reference document can be ordered through www.anrtheses.com.fr (use capital letters to fill in the boxes). - BOOK: “Le narguilé. Anthropologie d’un mode d’usage de drogues douces”, Ed. L'Harmattan, 1997, 262 pages. (English free translation): An Anthropology of Hookah. its Use and Soft Drugs, 262 pages.

  _______________ Notes: (*) For example, Hazelton’ s excellent study based on the use of a 2-stage clonal expansion model (incl. nested dose-response models for the parameters): “Smoking a bamboo waterpipe or a Chinese long-stem pipe appears to confer less risk than cigarette use, given equivalent tobacco consumption”. Why ? because “The arsenic-tobacco interaction also appears to be very important”, a point that previous studies (cited Lubin’s for instance), in the same country did not take into due consideration. (Hazelton, W. D., Luebeck, E. G., Heidenreich, W. F. and Moolgavkar, S. H. Analysis of a Historical Cohort of Chinese Tin Miners with Arsenic, Radon, Cigarette Smoke, and Pipe Smoke Exposures Using the Biologically Based Two-Stage Clonal Expansion Model. Radiat. Res. 2001, 156: 78-94)

  (**) Radwan GN et alii. Review on Waterpipe Smoking. J. Egypt. Soc. Parasitol. 2003 Dec;33 (3 Suppl):1051-71. Also note that this document is often referred to, in the related bibliography, as “cited in Israel” when it should be, if we mistake not, “cited in Radwan”.

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  Conflict of Interest:
  None declared.

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