When I was 16-years, I lived a very rough life and found myself in the foster-care pool. I came to live with Gloria and Bill Tuttle, and stayed for a few months. I was a very disturbed and distraught child, and I did not get along well with Gloria at all. (In hindsight it wasn't because she was mean, it was because she was in charge!!!) Bill was another story all together. He was quiet. Almost serene. He was tired a lot, and he always was in pain. He tried to hide it, but we could tell... I remember looking forward to walks with Bill and the other girls. I was always into medicine, and I am the type that when I don't understand something, I make it my mission. Bill answered my questions. ALL of them! He never tired of telling me anything I wanted to know about his illness. He told me once he wasn't afraid to die, only of dying too soon. When I asked him what he meant, he said that he wanted to tell everyone about his illness and what caused it, so no one else would have to live the way he did. He was such a good person for me at that time. Like a Grandpa. He would walk with me and hold my hand and tell me anything I wanted to know. I am sad that he died, but I am so proud of him for all his bravery. He was truly an extraordinary person. I am so blessed to have spent time with him and I hope lots of people learned from him and continue to even after his death...

Dear Editor,

Studying the social context of cigarette smoking was acknowledged as a pressing need in tobacco control. However, with new emerging health concerns like the growing use of the hookah (narghile) in the world, the social context, which bear similarities in both individual and collective smoking, also shows great differences that need to be reviewed. This letter introduces the reader to the specificities of collective smoking. It is based on a comprehensive and updated review of the related literature that includes several scientific books.

Recent efforts are geared towards the necessity of exploring further the complexity of the social context of smoking and its consequences on policy making. However, even if the background social theory is sometimes the same, the analysis in the case of individual smoking (cigarette) and collective smoking (hookah, narghile) is necessarily different in both cases and social scientists, as well as biomedical researchers, working in the field of tobacco control must be aware of similarities and differences.

For instance, a team of social scientists has recently published a study on the importance of the social context in tobacco control (1). An emphasis, placed so far on the disease or addiction model, would have resulted in negative consequences for the understanding of the human smoking behaviour. In this respect, this is particularly true in the case of fashionable hookah (narghile, shisha) smoking, our very field of research, where the social context is completely different from the one based on six dimensions: power relations, physicality (body in smoking), consumption patterns, social identity, desire and pleasure, place (1).

Apart from the peculiar traditional, historical and “exotic” aspects, we also have to deal with a collective (vs. individual) tobacco use mode with a particular staging of the “situation” with the meaning given to this last word by sociologist Ervin Goffman (2). In the USA, the interviewed hookah smokers themselves strongly insist in describing their practice as “social smoking” and, by coincidence, their peers in French- speaking countries use most of the time and spontaneously the word “conviviality”.

With all social scientists, we insist on the necessity of studying in depth the social representations related to smoking. In the case of narghile, we had to face a central one related to drug use so we decided to proceed as follows. We very early treated this question as a priority by publishing a core document on this aspect (3). This way, we avoided negative interferences with our further comprehensive approach of the other dimensions of hookah use in the world which are mainly related to tobacco use only (4).

Then, there is another set of social representations not to be found in the case of cigarette use: orientalism. On the one hand, this last concept is familiar for social scientists because the corresponding issue is considered as very serious in their field of work where a researcher like Edward Said (5) actually touched off an epistemological revolution. Unfortunately, on the other hand, biomedical researchers had no concrete clue for an evaluation of the relevance of such a concept in the field of tobacco control. So, we will limit here ourselves to cite a cogent publication on the subject (6) that develops further an earlier analysis (4).

As mentioned earlier, the central role of power relations, out of the six dimensions set out for any social context regarding cigarette smoking, was underscored (1). Notwithstanding, we wish to suggest an excellent relatively unknown study carried on in this respect where researchers actually showed how marginalized groups adopt unexpected strategies to adapt to a new situation posed by rises in tobacco prices. Just to mention one of them, they leave shorter butts which is unfortunately an extremely hazardous behaviour (7).

Then, once again, hookah smoking, as a collective practice, is different from cigarette use known to be individual. Both in traditional historical or modern social settings, the practice indistinctly covers the whole social spectrum. European travellers of the past centuries, to Asian and African traditional societies, were often startled by this sociological aspect and this was highlighted in their narrations (4). According to a famous anthropologist, the sultan would share his hookah with the street sweeper (8).

A second key dimension of the social context is physicality or the use of body in smoking (1). However, since a hookah is much bigger in size than a cigarette, the psycho-anthropological analysis differs in both cases with deep consequences on the physicality of smoking. Indeed, it is not only a question of how a cigarette is held by the smoker but how the body adapts to a device that can reach the size of a smoker sitting on a chair. The same Marcel Mauss, who actually created the “body techniques” (techniques du corps) concept, defined the latter as the ways and manners men, society by society, and in a traditional way, know how to use their body (9).

Excellent examples are given by the many orientalist paintings, where the narghile is omnipresent, but also in a recent article in the biomedical literature that features a young narghile female smoker lying by a swimming pool in Lebanon (10). The importance of the Maussian concept was further investigated and applied by other social scientists within the framework of what is now called “material culture” (6, 11).

Apart from the diverse dimensions of the social context, two main ideas should guide research work in the field of tobacco control. The first one is reflexivity defined as “maintaining a self critical attitude and questioning taken-for-granted assumptions regarding the (political) nature of our work and its (intended and unintended) effects, as well as the social distribution of these effects” (1).

Such an attitude will certainly have positive practical implications for policy makers and tobacco control activists. It may be seen as “novel”; however, it is familiar and natural for social scientists because this very interrogation is at the root of the anthropology discipline itself. Indeed, a scientist like Bourdieu was often considered as an anthropologist rather than a mere sociologist (4). In any case, this also shows the importance of collaboration between social and biomedical researchers.

The second important point is that the smokers’ voice would be rather absent from most of the studies. Indeed, this is one the first striking things any social scientist involved in tobacco control notice. In our early work on hookah smoking, we gave the transcripts of several unique face to face qualitative early interviews carried on in the Middle East (4). Such a literature reveals the many details to which some of our colleagues of the biomedical field did not pay the sufficient attention.

For instance, our findings were crucial in understanding the specificity, particularly pharmacological and behavioural, of the dependence process, completely different from that related to cigarette (12). On the daily life level, we can see that the so-called “hookah lounges” in the West already offer herbal fruit-flavoured tobacco-free smoking mixtures to their patrons. To close this chapter, we point out that our typology of the diverse tobacco-based smoking mixtures (tobamel, jurâk, tumbâk, etc.) was more than a mere ethnographic classification exercise (4, 13). For having ignored this point, the authors of recent and widely advertised studies, misled by a misnomer used by local scientists, actually mistook one type for another (14).

In conclusion, we invite our colleagues of both the social and biomedical sciences field to consider other forms of smoking and pay attention to the findings set out in this text. Some of them, like the hookah are gaining increased public health interest because of their dramatic development (15).

Kamal Chaouachi

REFERENCES

(1) POLAND B, FROHLICH K, HAINES RJ, MYKHALOVSKIY E, ROCK M. SPARKS R. The social context of smoking: the next frontier in tobacco control?. Tobacco Control 2006;15:59-63.

(2) GOFFMAN Erving (book). Les moments et leurs hommes. Seuil (Paris) 1988.

(3) CHAOUACHI Kamal (book). Le narguilé. Anthropologie d’un mode d’usage de drogues douces [Engl.: An Anthropology of Narghile: its Use and Soft Drugs], Ed. L'Harmattan, 1997, 262 pages.

(4) CHAOUACHI Kamal. Le narguilé : analyse socio-anthropologique. Culture, convivialité, histoire et tabacologie d’un mode d’usage populaire du tabac. Doctoral Thesis, Université Paris X (France), 420 pages. [Engl.: "Narghile (hookah): a Socio-Anthropological Analysis. Culture, Conviviality, History and Tobaccology of a Popular Tobacco Use Mode”].

(5) SAID Edward (book), L’orientalisme: L’Orient créé par l’Occident (orig. Title : Orientalism, 1978), Seuil (Paris) 1980.

(6) CHAOUACHI Kamal. Culture matérielle et orientalisme. L’exemple d’une recherche socio-anthropologique sur le narguilé, Arabica (Paris III Sorbonne et EHESS), 2006. Published by Brill (The Netherlands) [Engl.: Material Culture and Orientalism. The Example of a Socio-Anthropological Research on Narghile], 32 pages. Soon available online at www.brill.nl

(7) MOLIMARD R, AMRIOUI F, MARTIN C, CARLES P. Poids des mégots et contraintes économiques [Eng. Weight of Cigarette Butts and Economic Constraints]. La Presse Médicale 1994 ; 23 : 824-6.

(8) LEVI-STRAUSS Claude (book). Tristes tropiques [Eng. Sad Tropics]. Plon (Paris) 1955.

(9) MAUSS Marcel (book). Sociologie et Anthropologie. Presses Universitaires de France (Paris) 1968.

(10) CHAOUACHI Kamal. eLetter to the Editor: Some Misconceptions in a Good Alert Paper. Tobacco Control (18 January 2006). A critical analysis of the following study: AFIFI-SOWEID Rima. Lebanon: water pipe line to youth. Tobacco Control 2005;14:363-4. http://tc.bmjjournals.com/cgi/eletters/14/6/363-a#479

(11) WARNIER Jean-Pierre (book). Construire la culture matérielle : l’homme qui pensait avec ses doigts. Presses Universitaires de France (Paris) 1999.

(12) CHAOUACHI Kamal. Shisha, hookah. Le narguilé au XXIe siècle. Bref état des connaissances scientifiques. [Eng.: Narghile, Hookah in the 21st Century: An Overview of the Scientific Knowledge]. Le Courrier des Addictions 2004 (Oct) ; 6 (4) : 150-2.

(13) CHAOUACHI Kamal. Presentazione del narghilè e del suo uso. Guida critica della letteratura scientifica sul narghilè (shisha, hookah, waterpipe). Dalle origini ai giorni nostri : necessità di un approccio interdisciplinare socio-antropologico, medico e farmacologico. Tabaccologia (tabaccologia.org) 2005; 1: 39-47.

[Engl.: A critical review of scientific literature on narghile (Shisha, Hookah, Waterpipe) from its origins to date: the need for a comprehensive socio-anthropological, medical and pharmacological approach]. A tetralogy on all aspects of hookah smoking (further issues on Pharmacology, Pathologies and Public Health). All issues available at www.tabaccologia.org and www.tabaccologia.org/archivio.htm)

(14) Among others: NATTO S, BALJOON M, BERGSTROM J. Tobacco Smoking and Periodontal Health in a Saudi Arabian Population. Journal of Periodontology 2005; 76 (11): 1919-26.

(15) CHAOUACHI Kamal. The Recent Development of Hookah Use in the World : a Serious Epidemic or just a Passing Fad ? The Need for a Socio- Anthropological and Medical Approach. IFSSH (International Forum for Social Sciences and Health), World Congress “Health Challenges of the Third Millenium”. Istanbul, 21-26 Aug. 2005. Published by Yeditepe University, Dept. of Anthropology, Aug. 2005, tome I, pp. 360-1.

NOTE: A full English version or at least an official English abstract are available for most of the above cited references.

It would have to be seen as the most intriguing question of our era; to understand how, with all the most educated of scholarly voices abdicating for world wide smoking bans, how not one of those participants has the vision to see outside the box. To understand with very little imagination how beneficial it could be to society as a whole to simply look at the product before punishing it’s victims. When we view tobacco as one of the most dangerous products on the shelf, does it make sense to anyone it is also the only product on the shelf with no list of ingredients. While we are well informed as to the contents of, the smoke it could produce, it is downplayed how significantly the quantities present, individually or as a whole, represent a substantial risk. It is indisputable, the lack of ingredients list can be directly associated to the potential harm. If we look at what is revealed it is also indisputable many of the toxins and carcinogens could not be derived from the burning of Tobacco alone. The scientific community as a whole can still err in the description of the product as tobacco, either through lack of proper information or as a deliberate act to substantiate political will. Either excuse adds to the misinformation being supplied to the public with a scientific community rubber stamp of approval, contrary to well- established rules of informed consent. Human rights are no longer a priority in fact are being deliberately ignored in seek of the greater good. A major mistake, one which one-day, will greatly expand the list of names attributed to the Darwin awards. The danger is, the words scientific integrity could also be included on that list of casualties.

Simplistic regulation barring the use of known dangerous ingredients would reduce the harm of the product in its use. If as advocacy would proclaim the protection of health is the purpose for anti smoker advocacy perhaps the mortality figures stated as preventable could be greatly reduced by regulating the products. Of course, this would result in a decreased risk to non-smokers and the most efficient means of solving the problem at hand. Perhaps advocacy would be less effective if the numbers were reduced and we could deal with a more significant problem of violence and impunity, which is the most prominent effect of anti smoker advocacy.

The alternative is relying on case research studies investigating the effects of a range, of millions of possible combinations in the products being consumed. Predictably, we see a wide range of determined theoretic results of little scientific value. Further confusion added by the absolutes of smoking debates resulting in biases which undermine the credibility of any research study, with the current indicator being, who paid for the study as a judgment of integrity. No matter how much care and integrity was incorporated by the researcher, his absolute credibility will be determined by who pays the bill.

Is this the best we have to offer in the realm of scientific discovery? Facts by consensus and that consensus determined by the size of our gang, our ability to create facts or having the finances to establish those facts in the media and through that a silencing of all opposition. Public confidence in the process is understandably reserved to say the least.

It was revealed to me today the president of mychoice.ca in Canada was threatened with death on her doorstep for nothing more than a perceived threat she represents, as a non-smoker advocating for nothing more than respect of her neighbors in community. She has never stated smoking is not dangerous and has consistently stated it is, in every public discussion. She was once given an award by her peers speaking out on the topic of violence against women. Now she is disassociated from integrity in her opinion, in advocacy against the same topic, Hatred and Violence. Where are the advocates rushing to her aid and praise this time around? Have our values now changed so absolutely it is permissible to excuse the abuse of others as long as we can create a good enough reason? Not original in fact in 1930s Germany those same assessments were made Praised and encouraged internationally, using the smoking issue as a wedge to join the parties in health advocacy lobbying, we know how that turned out, how soon we did forget. On the other hand, perhaps we are smarter now and are assured the results will be different. Consistent with the insanity theory of repetitive actions expecting a different result. Lunacy? I would say so.

Are we so bent we cannot see the damage to us all here? The bullies are campaigning confidently and without fear of reprisals, for barring a smoker from Employment, Housing or Community Many others join in declaring child abuse against parents in custody hearings could be justifyable. The Ontario Government dispensing hatred to our children endorsed and applauded, at a site they call stupid, it’s very name screams violence, this is indefensible by a government in a civilized society yet no one noticed. The same Government ministry has recently announced a couple of decries of note; "Quit or be punished" and more recently "Fat is the new tobacco" Will the term fat have a similar wide berth of definition in science, so we can repeat the process in the coming decade? Now they approach our homes the castle to some will be a fortress to others, defending their fading right to escape from their insidious tormentors.

The diagnosis should be clear we could do a lot better. The alternative again could be defense of a momentous lawsuit on our horizon in the civil rights abuses against the victims of both the product and the gang of bullies. Justice will have the final say in the campaign of hatred, a deliberately created pandemic in our culture.

Does a smoking ban result in protection of non-smokers who now deal with an increasingly meaner more violent society? Do we reduce preventable death by ignoring the cause? Can any deny informed consent is not well served in our current approach?

If any are determined enough to answer yes to any of these questions; a self-examination is in order, to understand your need to express intolerance and abdicate for crimes against others for the use of a legal product.

Food for thought From the British Medical Journal; http://tc.bmjjournals.com/cgi/content/full/14/suppl_2/ii3?ijkey=51532084409cd1fe36c22cbb2fb51ee231739f0c

The trial testimony of Sanford Barsky, offered by David Egilman in his email letter to Tobacco Control, provides an illustrative example of why tobacco industry sponsored research should not be published in Tobacco Control or other responsible scientific periodicals. In the testimony Barsky argues for non-tobacco causation of a case of squamous cancer of the lung. Examination of tobacco industry documents housed in the Legacy Tobacco Documents Library http://www.legacy.library.ucsf.edu reveals that the tobacco industry organized and funded an effort, Council for Tobacco Research (CTR) Special Projects (SP) 47 and 110, to recruit eminent physicians to identify cases of epidermoid (squamous) carcinoma of the lungs in non-smokers. [1], [2] This search was important to the tobacco industry because of public testimony by prominent pathologists like Oscar Auerbach MD that he "had never seen a case of squamous cancer in a nonsmoker". [3] The stated purpose of SP-110 was "To demonstrate that epidermoid lung cancers do occur in nonsmokers and thus refute assertions that these cancers occur only in smokers." [4] This research effort was led by pathologist Lauren Ackerman MD and included a number of thoracic surgeons, including Society of Thoracic Surgeons president Lyman Brewer III.MD and Thomas Burford MD Chair of Thoracic Surgery at Washington University. Ackerman, a pathologist at Washington University was the recipient of a $3.6 million tobacco industry research grant. [5] Also involved in SR-110 was Yale epidemiologist Alvan Feinstein PhD, who received more than $2 million from the industry during his long career. Other participants in the study are listed in a footnote below. Of these individuals, only Feinstein ever published on the topic. He reported after a review of medical records that he had found 17 cases of epidermoid cancer in non-smokers. This assertion prompted a review and 1970 publication by Yale pathologists Raymond Yesner and N.A. Gelfman who determined that none of Feinstein's cases were, in fact, epidermoid cancers. Remarkably, although he was a coauthor on this publication, in two letters to the editors of JAMA and the Medical Tribune, Feinstein "regretted the premature publication" and disassociated himself from Yesner's conclusions, stating that he did not believe that epidermoid cancer was a "tobacco cancer" based upon his interpretation of data. [6][7] Finally, in 1973 another reexamination of 449 Yale lung cancer cases by the same authors confirmed that the incidence of squamous and small cell lung cancers is very uncommon in non-smokers (approximately 1%). There were no cases among non-smoking men. [8] In 1974, Feinstein took a new tack, suggesting that the reason that there was an increase in lung cancer in smokers was a "bias" on the part of clinicians who were more likely to consider a diagnosis of lung cancer and initiate testing for the disease in smokers. [9] No publication on this topic by any of the other researchers involved in SP-110 could be found in a search of the Index Medicus. The clear implication is that none of the experts could find cases of squamous lung cancer in non-smokers in the records of their medical centers. This should cause no surprise to clinicians and pathologists experienced in the care of lung cancer, who know that cases of such cancers in non- smokers are rare. It is also reasonable to assume that, if the SP-110 and SP-47 investigators had identified cases of squamous lung cancer in never-smokers, the results would have been published and trumpeted by the industry in courtroom testimony. The fact that the results of SP-110 were not published reflects the willingness of the tobacco industry to stifle publication of adverse results, and represents a clear and typical example of the insidious and self-serving nature of tobacco industry funded research. Good science involves the publication of all results, not just those that serve the agenda of a killer industry. Appendix:

Physicians and scientists mentioned in documents as participating in these CTR "Special Projects"included. Robert E. Stowell MD Dean Davies Lauren Ackerman MD St.Louis MO Avrill Liebow MD New Haven CT Samuel G. Taylor MD Chicago IL Russell Irwin MD San Diego CA William H. Sheffield MD Thomas Burford St. Louis MO Haynes Shepherd San Diego TS Homer Peabody MD San Diego CA John R. Kiser MD San Diego CA Alvan Feinstein MD New Haven CT Doris Herman Los Angeles CA Lyman Brewer MD Los Angeles CA

References:______________________________ [1]http://legacy.library.ucsf.edu/cgi/getdoc?tid=zxz95a00&fmt=pdf&ref=res ults ; "Special Project # 47." Bates # 92613988 [2]http://legacy.library.ucsf.edu/cgi/getdoc?tid=aqw90c00&fmt=pdf&ref=res ults ; "Special Projects" January 1, 1968. Bates #995007392 [3]http://legacy.library.ucsf.edu/cgi/getdoc?tid=dod3aa00&fmt=pdf&ref=res ults Memorandum Leonard Zahn and Associates "American College of Surgeons". Bates # unknown. [4]. http://legacy.library.ucsf.edu/tid/ydm06a00 "Collect Cases of Epidermoid Lung Cancer in Non-Smokers". Bates # 955008212 19660226 American Tobacco Company [5]http://legacy.library.ucsf.edu/cgi/getdoc?tid=dzg33f00&fmt=pdf&ref=res ults ; "Washington University March 1971". Bates # 680601980 [6] Feinstein AR. Smoking and cancer morphology. JAMA. July 6, 1970, 213:131 [7]Feinstein AR. Smoking-histology study. Medical Tribune 1 June 1970;33:11. [8]Yesner R, Gelfman NA, Feinstein AR. Reappraisal of histopathology in lung cancer and correlation of cell types with antecedent smoking. Am Rev Resp Dis 973;107:790-7 [9]Feinstein AR, Wells CK. Cigarette smoking and lung cancer: the problems of "detection bias" in epidemiologic rates of disease. Trans Assoc Am Physicians. 1974;87:180-5