Article Text

Download PDFPDF
Toxicant inhalation among singleton waterpipe tobacco users in natural settings
  1. Mohammed Jawad1,
  2. Thomas Eissenberg2,3,
  3. Rola Salman3,4,
  4. Eric Soule2,3,
  5. Karem H Alzoubi5,
  6. Omar F Khabour6,7,
  7. Nareg Karaoghlanian3,4,
  8. Rima Baalbaki8,
  9. Rachel El Hage8,
  10. Najat A Saliba3,4,
  11. Alan Shihadeh3,4
  1. 1 Public Health Policy Evaluation Unit, Imperial College London, Hammersmith, UK
  2. 2 Department of Psychology, Virginia Commonwealth University, Richmond, Virginia, USA
  3. 3 Center for the Study of Tobacco Products, Virginia Commonwealth University, Richmond, Virginia, USA
  4. 4 Mechanical Engineering Department, American University of Beirut, Beirut, Lebanon
  5. 5 Department of Clinical Pharmacy, Jordan University of Science and Technology, Irbid, Jordan
  6. 6 Department of Medical Laboratory Sciences, Jordan University of Science and Technology, Irbid, Jordan
  7. 7 Faculty of Applied Medical Sciences, Taibah University, Medina, Saudi Arabia
  8. 8 Department of Chemistry, American University of Beirut, Beirut, Lebanon
  1. Correspondence to Professor Alan Shihadeh, Faculty of Engineering and Architecture, American University of Beirut, Beirut, Lebanon; as20{at}


Background Studies that assess waterpipe tobacco smoking behaviour and toxicant exposure generally use controlled laboratory environments with small samples that may not fully capture real-world variability in human behaviour and waterpipe products. This study aimed to conduct real-time sampling of waterpipe tobacco use in natural environments using an in situ device.

Methods We used the REALTIME sampling instrument: a validated, portable, self-powered device designed to sample automatically a fixed percentage of the aerosol flowing through the waterpipe mouthpiece during every puff. We recruited participants at café and home settings in Jordan and measured puffing behaviour in addition to inhalation exposure of total particulate matter (TPM), carbon monoxide (CO), nicotine, polycyclic aromatic hydrocarbons and volatile aldehydes. We correlated total inhaled volume with five selected toxicants and calculated the regression line of this relationship.

Results Averaged across 79 singleton sessions (52% male, mean age 27.0, 95% home sessions), sessions lasted 46.9 min and participants drew 290 puffs and inhaled 214 L per session. Mean quantities of inhaled toxicants per session were 1910 mg TPM, 259 mg CO, 5.0 mg nicotine, 117 ng benzo[a]pyrene and 198 ng formaldehyde. We found positive correlations between total inhaled volume and TPM (r=0.472; p<0.001), CO (r=0.751; p<0.001), nicotine (r=0.301, p=0.035) and formaldehyde (r=0.526; p<0.001), but a non-significant correlation for benzo[a]pyrene (r=0.289; p=0.056).

Conclusions In the natural environment, waterpipe tobacco users inhale large quantities of toxicants that induce tobacco-related disease, including cancer. Toxicant content per waterpipe session is at least equal, but for many toxicants several magnitudes of order higher, than that of a cigarette. Health warnings based on early controlled laboratory studies were well founded; if anything our findings suggest a greater exposure risk.

  • carcinogens
  • nicotine
  • smoking topography

Statistics from

Request Permissions

If you wish to reuse any or all of this article please use the link below which will take you to the Copyright Clearance Center’s RightsLink service. You will be able to get a quick price and instant permission to reuse the content in many different ways.


  • Contributors Study conception and design: AS and TE. Acquisition of data: AS, KHA, OFK, RB, RE-H, RS, NK and TE. Analysis and interpretation of data: AS, EKS, KHA, MJ, OFK, RE-H, RS and TE. Drafting of manuscript: AS, KHA, MJ, OFK, RS and TE. Critical revision: AS, EKS, KHA, MJ, NAS, NK, OFK, RB, RE-H, RS and TE.

  • Funding This study was funded by NIH/NIDA grant number R01 DA025659. TE, Saliba, EKS and AS currently are supported by the National Institute on Drug Abuse of the National Institutes of Health under Award Number P50DA036105 and the Center for Tobacco Products of the US Food and Drug Administration.

  • Disclaimer The content is solely the responsibility of the authors and does not necessarily represent the views of the NIH or the FDA.

  • Competing interests None declared.

  • Patient consent Not required.

  • Provenance and peer review Not commissioned; externally peer reviewed.