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Evidence of compensation among waterpipe smokers using harm reduction components
  1. Marielle C Brinkman1,2,
  2. Hyoshin Kim3,
  3. Stephanie S Buehler4,
  4. Anna M Adetona4,
  5. Sydney M Gordon4,
  6. Pamela I Clark2
  1. 1 College of Public Health, The Ohio State University, Columbus, Ohio, USA
  2. 2 School of Public Health, Tobacco Center of Regulatory Science, University of Maryland, College Park, Maryland, USA
  3. 3 Battelle Public Health Center for Tobacco Research, Battelle, Seattle, Washington, USA
  4. 4 Battelle Public Health Center for Tobacco Research, Battelle, Columbus, Ohio, USA
  1. Correspondence to Marielle C Brinkman, College of Public Health, The Ohio State University, Columbus, Ohio 43210, USA; brinkman.224{at}


Objectives We examined two waterpipe tobacco smoking components advertised to reduce harm to determine if they result in lower levels of biomarkers of acute exposure.

Methods We conducted a crossover study of 34 experienced waterpipe smokers smoking a research-grade waterpipe in three configurations ad libitum in a controlled chamber: control (quick-light charcoal), electric (electric heating) and bubble diffuser (quick-light charcoal and bubble diffuser). We collected data on smoking topography, environmental carbon monoxide (CO), subjective effects, heart rate, plasma nicotine and exhaled CO and benzene.

Results Smokers’ mean plasma nicotine, heart rate, and exhaled benzene and CO boost were all significantly lower for electric compared with control. However, smokers puffed more intensely and took significantly more and larger volume puffs for a larger total puffing volume (2.0 times larger, p<0.0001) when smoking electric; machine yields indicate this was likely due to lower mainstream nicotine. Smokers rated electric smoking experience less satisfying and less pleasant. For charcoal heating, the mean mass of CO emitted into the chamber was ~1 g when participants smoked for a mean of 32 minutes at a typical residential ventilation rate (2.3 hr−1).

Conclusion Waterpipe smokers engaged in compensation (i.e., increased and more intense puffing) to make up for decreased mainstream nicotine delivery from the same tobacco heated two ways. Waterpipe components can affect human puffing behaviours, exposures and subjective effects. Evidence reported here supports regulation of waterpipe components, smoking bans in multifamily housing and the use of human studies to evaluate modified or reduced risk claims.

  • addiction
  • nicotine
  • secondhand smoke
  • carcinogens
  • global health

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  • Contributors MCB, SMG and PIC were responsible for the conception and design of the study. SSB was responsible for the chemical analysis, and HK and AMA were responsible for the statistical analysis. All contributed to the analysis and interpretation of the data and the preparation of the manuscript.

  • Funding Research was supported by grant number R01CA133149; the preparation of the manuscript was supported by P50CA180523 from the Office of the Director, National Institutes of Health (OD), National Cancer Institute and the FDA Center for Tobacco Products.

  • Disclaimer The content is solely the responsibility of the authors and does not necessarily represent the official views of the NIH or the Food and Drug Administration.

  • Competing interests None declared.

  • Patient consent Not required.

  • Ethics approval The study was approved by the Battelle Internal Review Board (FWA 0004696).

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

  • Data sharing statement In accordance with P.L. 110-161, this article is publicly available on PubMed Central. Additional methodology and data are available in the supplementary file.