This is to comment on
the following recently published study:
Ward KD,
Eissenberg T, Rastam S, Asfar T,Mzayek F, Fouad MF, Hammal F,Mock J, Maziak W. The
tobacco epidemic in Syria. Tobacco Control 2006;15;24-29.
About
the So-Called Epidemic and the Poor Smoking People
The paper is globally unbalanced in
favour of a certain focus on narghile (hookah, shisha) smoking. After reading
the three following quotations, the reader may wonder whether we can call
hookah smoking an “epidemic” in Syria:
1-"The
prevalence of cigarette smoking was 56.9% for men and 17.0% for women, while
the prevalence of waterpipe smoking was 20.2% for men and 4.8% for women (fig 1)"
2-"The
opposite pattern was observed for waterpipe, with 1.0% smoking daily (1.4% for
men and 0.6% for women), and 10.6% smoking occasionally (18.8% of men and 4.2%
of women). The prevalence of combined daily use of cigarette and waterpipe was
reported rarely—0.1% (0.1% men, 0.1% women)."
3-"Daily
cigarette smokers averaged 20.8 (SD 14) cig/day (23.6 (13.9) for men and 12.8
(11) for women), while weekly waterpipe smokers smoked on average 1.7 (1.1)
waterpipe/week (1.6 (1) for men and 1.7 (1.4) for women)."
We encourage our
colleagues to inform the Syrian Ministry of Health of these statistics and urge
it to take steps to curb the cigarette epidemic in this country. Of course the
task is huge because of the nature of the market and the diverse interests at
stake. Syrians smoke national, international, smuggled and counterfeited
cigarettes. Certainly the solution is regional integration and cooperation.
Syria and Lebanon, where more than a half of the population smokes cigarettes
in both countries, can work hand in hand towards a Middle East free from
tobacco all the more that they are one same people.
So, we are afraid
“epidemic” might not be the best word to describe the revival of narghile use
in the Middle East. Besides, a corresponding scenario was proposed two years
ago by the same team (1). According to it, the Arab information satellite
television channels would have been greatly responsible for the development of
the hookah craze. Unfortunately, such a conclusion is not in agreement with
our socio-anthropological
research findings in the Middle East which point to at least 15 factors set out
and analysed in an early document (2).
Now, if "quitting
is also more prevalent among waterpipe smokers especially in the poorer
sections of the society", then this is good news because one reason
behind the failures of many tobacco prevention programmes in the world is not
dealing with the health consequences of poverty in this field. By good fortune,
great original researchers showed how marginalized groups adopt unexpected
strategies to adapt to any new situation stemming from rises in tobacco prices.
Just to mention some of them, they may leave shorter butts which is
unfortunately an extremely hazardous behaviour (3). They may also hand-roll
cigarettes that pose higher oral cancer risks (4). More, they can stuff hand
rolled cigarettes with the remaining tobacco from the butts of other, used
filters and dry leaves, or share the same cigarette (5).
About Carbon
Monoxide Levels
“Results suggest that waterpipe users are exposed to
more CO than previously reported (we observed a mean increase from 5.6 ppm
before use to 36.3 ppm after use (p , 0.01), compared to the mean of 14.2 ppm
after waterpipe use reported by Shafagoj and Mohammed)”.
This fact may be surprising for the
authors. However, this is in agreement with our own findings so we will be
happy to comment on it but only when the corresponding study is out since it is
only an announcement. Indeed, we regret that the authors too often refer to
forthcoming publications.
About
the Adaptation of Questionnaires
Kozlowski actually
warned against the misuse, in English, of the words “craving” and “urge” (6,
7). So, we really wonder how, in a sophisticated language like Arabic, these
concepts, and the subtleties they convey, will be rendered in a corresponding
translated questionnaire. Many studies in this field refer to “adapted”
versions of internationally known and validated questionnaires (like
Fagerstrom’s, Tiffany–Drobes’, Prokorov’s, Hughes-Hatsukami’s, etc.) and,
sometimes, to an Arabic “version” of them. However, they are never made public.
Since science is based on the possibility offered for any researcher to
reproduce, in the same conditions, any experience previously carried on, we
think the so-called documents should be annexed to the studies publishing the
corresponding results. Indeed, it is all the more easy that in most cases the
adapted questionnaires are very short in length. From there, we hope to see the
Arabic version of the Tiffany-Drobes questionnaire published soon so our team,
presently working on dependence patterns, can test, in its turn, its claimed
applicability.
Also note that the
same Kozlowski warned against the use of smoking machines in the field of
cigarettes, where, however, the smoking session (c. 5 minutes) is extremely
short in comparison with the hookah (30-60 minutes)(8). So, this kind of cogent
reflection may render questionable a certain number of findings (9).
About
Initiation Age
Strangely enough, statistics reveal
that there is no so-called children use in Syria:
"Age of initiation differed according to method
of smoking and gender. On average, men initiated use of cigarettes at age 17.9
(5.3) years and waterpipe at 25.5 (9.1) years, while women initiated use of
cigarettes at 22.5 (8.4) years and waterpipe at 28.9 (9.9) years (p , 0.05 for
all gender and smoking method comparisons by t test)."
Consequently, and
since Syria is an Arab country, this result is apparently not in agreement with
the first Advisory Note on “Waterpipe” smoking ever published by WHO (World
Health Organisation). This last document states, among other errors that could
have been avoided, that in the Arab world (described as “South-West
Asia and North Africa”):
“it is not uncommon for children to smoke with their parents” (10). In fact, our
socio-anthropological work showed that in Syria as in many other countries of
the region, narghile (hookah, shisha) initiation is more akin to a kind of
“rite of passage” (2).
About
Dependence
"Less
interest in quitting and a higher quit rate among waterpipe users compared to
cigarettes possibly indicate lower level of nicotine dependence among waterpipe
users."
In a former study (11), on
which we already commented (12), one assumption was that"nicotine dependence may also result from repeated inhalation of
tobacco smoke from a waterpipe [...] Until recently, no studies have
characterised a waterpipe withdrawal study of seven waterpipe using men, daily
use was associated syndrome, though some of the hallmarks of dependence are
apparent: continued use despite potential health risks, financial cost, and
reported inability/difficulty quitting."
In order to spare
time and from our original transdisciplinary experience, we would be happy if
our colleagues would accept to contemplate other possible research orientations
in this important field. Indeed, on one hand, original research on narghile
will help, not only understand the dependence phenomenon related to the use of
narghile, but also the dependence process as a whole and, most importantly,
regarding cigarette smoking. People do not necessarily smoke the hookah for
nicotine and another evidence for this is that the fashionable “hookah lounges”
already offer herbal fruit-flavoured tobacco-free smoking mixtures to their
patrons.
On the other hand,
there is a serious debate over the central role of nicotine in the dependence
process (13). Indeed, the importance of flavours (only in the case of tobamel,
the popular tobacco-molasses based smoking mixture) would make the dependence very
similar to that induced by coffee (14). Thus, not only nicotine but MonoAmine
Oxidase Inhibitors (MAOI), other not so « important » low-dose
potentially dependence-inducing alkaloids, ligands of opioid receptors, and
other substances, might play a not so minor role in the dependence process
(15).
About
Anthropological Work
The paper refers to a
“new” orientation of the team activities within the framework of the so-called
“grounded theory approach”. Here, we would like to emphasise that the
anthropological work implies very long observation periods. In our case, we
actually carried on early socio-anthropological work in the Middle East for a
period of four years. We have interviewed hookah users and drawn, only in the
last stage, relevant and originalconclusions,
particularly regarding dependence (2). We regret that the authors openly
present “preliminary” results or analysis of an ongoing work of this nature.
This is not possible. From the very methodological point of view of
anthropology, we are afraid this cannot be done and this is one of the
peculiarities of some social sciences.
Poland et al. have
clearly shown in the columns of this journal where the last frontiers of
tobacco control are (16). Their rare and deep analysis is valid for any country.
In the light of the debate over orientalism opened by Edward Saïd (17) to an
unexpected horizon, we scientists (particularly from the Middle East or of
Middle East origin), either from the biomedical or social science field, will
be answerable for the way we have been doing science (18). Do we make it with
the people and for the people and their health or for academic research only -
sort of Art for art’ sake ? From this perspective, we commented on Poland’
study and showed the actual similarities and dissimilarities between both the
cigarette and hookah worlds (19). So, why not take advantage of the recent
archives of this journal ?
A statement we fully
agree is : "What is unique and worrisome about the
waterpipe is its use as a substitute for cigarettes after quitting, and the
fact that the waterpipe was the trigger of relapse for some cigarette quitters.
Thus, initiation of waterpipe use can be a significant unintended consequence
of cigarette smoking cessation." Indeed, we are glad to see how our colleagues
now share the conclusions we drew more than five years ago (2, 20, 21).
About
the word “water-pipe”
We are afraid this
word is misleading and deepens the gap between scientists and the true world of
hookah users. Please refer to our critique of a paper in the columns of this
same journal (22). Indeed, we are quite sure that our colleagues will never
use, in a related study or questionnaire into Arabic, “galyûn bi-l-mâ‘
(or galyûn mâ‘î), which are, as they may know, laughable literal
translations of “water-pipe”.We are
sure they would use the words “narghile” or “shisha” (“hookah” if they were in
India or Pakistan). Indeed, they will understand that it would be funny to
imagine a naïve anthropologist asking smokers in a Syrian coffee-house: What
about your “galyûn bi-l-mâ‘” practice ?
Indeed, in this field
where tradition and the sociocultural context meet so closely with
pharmacology, it is of utmost importance to use the language the people use
then reflect this in our publications. Further to a comprehensive analysis of
the world linguistic variations and the higher observed prevalence for some of
them, we concluded that three terms are highly relevant: narghile , hookah and
shisha (2). These words can be found in any good English academic dictionary.
Shisha is now used internationally because of the global hookah craze whereas
“waterpipe”, we are afraid,is no
hypostasis. More, we have noted how this word creates bibliographic noise in
databases since it also refers to household infrastructure plumbing equipments…
Certainly the artefact is a “water-pipe” in a chemistry laboratory (9).
However, once you are in the street or in a domestic setting, it is a hookah, a
narghile, a shisha and even much more. This stresses, once more, the importance
of a scientific discipline like anthropology whose object is not the study of
folklore.
About Capacity
Building
The so-called RAM
(Research Assistance Matching) action was already advertised in the Science
journal and we had the opportunity to comment on it by emphasising the fact
that the best studies in the field of hookah smoking have been carried on in
the South with no external aid (23). For instance, who could say that Shafagog
(24), who worked with a small team in a poor country like Jordan, was lacking know-how,
ignoring international best practices or expertise ? He has actually produced
the best reference studies on cotinine/nicotine levels and an excellent other
one on CO intake in true narghile smokers.
The same applies for
Sajid (25) and his team in Pakistan, whose findings, obtained with modest
means, contributed in pushing forward research. He had this fantastic idea of
measuring CO levels according to the size of the device, the nature of the
tobacco-based mixture and even the charcoal varieties. He and his colleagues
are simply brilliants. They remained relatively unknown for a very long time
until we described their work six years ago then advertised it here and there
(2). We could follow with many other examples from the so-called South.
So, what we defend is
a capacity building project that takes into account other dimensions than the
RAM one. The objective of ours, hopefully soon carried on with the
collaboration of the prestigious University of La Sapienza, is to train
Western researchers on the specificities of the socio-cultural context of the
countries where hookah smoking seems to cause a problem for certain
authorities. Perhaps the RAM project may be of some use for cigarette smoking.
However, for narghile, our own opinion is that we definitely need not new or
modern methodologies or approaches. What we need are ideas that originate from
the local context. We have already helped dozens of researchers in this new way
of thinking and we hope to train more and more people in the future on these trailblazing
conceptual frameworks.
Kamal Chaouachi,
Researcher in Socio-Anthropology and Tobaccology
Consultant in Tobacco Control (Paris)
REFERENCES
(1) RASTAM S, WARD KD, EISSENBERG T,
MAZIAK W. Estimating the beginning of the waterpipe epidemic in Syria. BMC
Public Health 2004; 4:32.
(2) CHAOUACHI Kamal. Le
narguilé : analyse socio-anthropologique. Culture, convivialité, histoire
et tabacologie d’un mode d’usage populaire du tabac. Transdisciplinary
doctoral thesis, Université Paris X (France), 420 pages. [Engl.: "Narghile (hookah): a
Socio-Anthropological Analysis. Culture, Conviviality, History and
Tobaccologyof a Popular Tobacco Use
Mode”].
(3)
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.
(4) DE STEFANI E, OREGGIA F, RIVERO
S, FIERRO. Hand-rolled cigarette smoking and risk of cancer of the mouth,
pharynx, and larynx. Cancer
1992 (Aug 1);70(3):679-82
(5) ALOOT CB, VREDEVOE DL, BRECHT ML. Evalutation of high-risk smoking
practices used by the homeless. Cancer Nursing 1993; 16 : 1202-3
(6) KOZLOWSKI LT, MANN RE, WILKINSON DA,
POULOS CX. "Cravings"
are ambiguous: ask about urges or desires. Addict Behav. 1989;14(4):443-5.
(7) KOZLOWSKI LT, WILKINSON DA. Use and misuse of the concept of
craving by alcohol, tobacco, and drug researchers. Br J Addict. 1987 Jan;82(1):31-45.
(8) ZIELINSKI S. Smoking Machine
Test Inadequate and Confusing, But No Replacement a Decade Later. Journal
of the National Cancer Institute 2005 (Jan 5); 97 (1): 10-1.
(9)
SHIHADEH A,SALEH R. Food and
Chemical Toxicology : Polycyclic aromatic hydrocarbons, carbon monoxide, “tar”,
and nicotine in the mainstream smoke aerosol of the narghile water pipe. Food
and Chemical Toxicology 2005; 43(5): 655-661.
(10) WORLD HEALTH ORGANISATION.
Advisory Note: Waterpipe Tobacco Smoking: Health Effects, Research Needs and
Recommended Actions by Regulators. Tobacco Free Initiative 2005. Retrieved
15 Dec. 2005 from: www.who.int/tobacco/global_interaction/tobreg/en/
(11) 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: 327-333.
(12) CHAOUACHI K. eLetter to the
Editor: Serious Errors in this Study. Tobacco Control 2004 (2 Dec.). A
critical analysis of the above study http://tc.bmjjournals.com/cgi/eletters/13/4/327
(13) FRENK HANAN, DAR REUVEN (book). A
Critique of Nicotine Addiction. Kluwer Academic Publishers (Boston) 2000.
(14) CHAOUACHI K. Tabacologie
du narguilé [Eng.: Tobaccology of Narghile]. Alcoologie. 1999; 21
(1/83):88-9.
(15) MOLIMARD R.. Dépendance,
la nicotine est-elle la seule responsable ?[Eng.: Dependence. Is nicotine solely
responsible ?]Soins Psychiatr 2001 (May-Jun);(214):33-5.
(16) 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.
(17) SAID Edward (book). Orientalism. Routledge & Kegan Paul 1978 (London).
(18)
CHAOUACHI K. Culture matérielle et orientalisme. L’exemple d’une recherche
socio-anthropologique sur le narguilé. Arabica, tome LIII,2, 177-209. Koninklijke Brill NV (Leiden) 2006. [Engl.: Material Culture and Orientalism.
The Example of a Socio-Anthropological Research on Narghile](www.brill.nl )(available here
or contact author)
(19) CHAOUACHI K. Letter to the
Editor: The Social Context of Individual and Collective Smoking: Similarities
and Differences. Tobacco Control 2006 (1 April). A critical analysis of Poland’ study. http://tc.bmjjournals.com/cgi/eletters/15/1/59
(20) CHAOUACHI K. 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. Full
English version available.
(21) CHAOUACHI Kamal. A 60 page tetralogy on narghile (hookah)
smoking and health published in Tabaccologia, the official Journal of
the Italian Society of Tobaccology: Introduction (Tabaccologia 2005; 1:
39-47); Pharmacology (2005; 3: 27-33); Health Aspects (2006;1:27-34); Prevention (forthcoming).
Includes English abstracts. www.tabaccologia.org/archivio.htm
(22)
CHAOUACHI K. Letter to the Editor: Some Misconceptions in a Good Alert Paper.
Tobacco Control2006 (18 Jan.). A critical analysis of the following
study: AFIFI-SOWEID
Rima. Lebanon: water pipe line to youth. Tobacco Control 2005;14:363-4.
(23) CHAOUACHI K. Letter
to the Editor: Arabs
Neither Need a Scientific Revolution Nor Are They a Cultural Exception. Science (eLetter, 07 March 2006). A critical analysis of the following
study: MAZIAK W. Global
voices of science. Science in the Arab world: vision of glories beyond. Science.
2005 Jun 3;308(5727):1416-8.
(24) 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(6):249-55.
(25)
SAJID KM, AKTHER M, MALIK GQ (1993 Sep). Carbon monoxide fractions
in cigarette and hookah. J Pak Med Assoc.; 43(9):179-82.
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...
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...
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 specificit...
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.
Less Harmful cigarettes do exist, but the majority of the smoking
public is unaware that they are available. Isn't it about time that our
government establish an agency that would regulate all tobacco products? I
have recently been made aware of a new company that makes a less harmful
cigarette. The companies name is Wellstone Filters(lowertar.com), and they
have a developed a special cigarette filter that is patented and...
Less Harmful cigarettes do exist, but the majority of the smoking
public is unaware that they are available. Isn't it about time that our
government establish an agency that would regulate all tobacco products? I
have recently been made aware of a new company that makes a less harmful
cigarette. The companies name is Wellstone Filters(lowertar.com), and they
have a developed a special cigarette filter that is patented and FTC
tested that screens out up to 95% of all carcinogens in cigarette smoke.
It looks and acts just like a regular cigarette filter. Why don't all
cigarettes manufactures use these or similar filters to provide a less
harmful cigarette?
If the FDA would regulate tobacco, the public could benefit from many new
less harmful products. The citizens of our great free country have every
right to enjoy a relaxing smoke, and why not make them less harmful! The
anti smoking public would be better served if they would focus there
energy toward getting our governmental agencies to demand from the tobacco
companies less harmful tobacco products! It could all begin with the FDA
regulating tobacco products!
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 a...
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
I read the article by Offen et al with great interest. It is an
excellent elucidation of the concepts of ‘boycott,’ ‘buycott,’ and
‘perimetric.’ One opportunity for perimetric action not mentioned is the
option each academic has to boycott and/or draw attention to universities
and medical schools that accept tobacco industry funds or hold tobacco
stock. (1) The converse is equally appropriate; ‘buycott’ centers that
hav...
I read the article by Offen et al with great interest. It is an
excellent elucidation of the concepts of ‘boycott,’ ‘buycott,’ and
‘perimetric.’ One opportunity for perimetric action not mentioned is the
option each academic has to boycott and/or draw attention to universities
and medical schools that accept tobacco industry funds or hold tobacco
stock. (1) The converse is equally appropriate; ‘buycott’ centers that
have clear policies abhorring tobacco investments or funding.
When information on such policies – or the lack of them – becomes freely
available, we can engage in “less research and more action” as has been
suggested elsewhere. (2)
1. Wander N, Malone RE. Selling Off or Selling Out? Medical Schools
and Ethical Leadership in Tobacco Stock Divestment. Acad Med
2004;79(11):1017-26.
2. Blum A, Solberg E, Wolinsky H. The Surgeon General's report on smoking
and health 40 years later: still wandering in the desert. Lancet
2004;363(9403):97-8.
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...
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
While I'm delighted that these tobacco industry trial products of
unproven merit continue to "taste like s__t" (-a reference to the RJR
president's famous quote in "Barbarians at the Gate"), I hope that we'll
not see much more of OSH's time spent on what amounts mostly to market
research valuable to the tobacco malefactors.
I certainly agree with most of the comments of Dr
Kamal Chaouachi but the need to develop one generic
name for the different types of this form of tobacco
smoking is definite and we tend to prefer the term water-
pipe smoking as it denotes the similarity that links all
these forms and shapes and local names. Certainly
these different names are associated with local
geographical languages and idenified best in the
reps...
I certainly agree with most of the comments of Dr
Kamal Chaouachi but the need to develop one generic
name for the different types of this form of tobacco
smoking is definite and we tend to prefer the term water-
pipe smoking as it denotes the similarity that links all
these forms and shapes and local names. Certainly
these different names are associated with local
geographical languages and idenified best in the
repsective languages. The need to use a common generic name is recognized
to avoid using three to five different names in every paper to make sure
that the study covers these
types. Water-pipe tobacco smoking is a good common
name and reflects the major difference from direct
tobacco smoking which is a lower temperature of
burning as well as cooler smoke temperature. This is
reflected in the composition of the smoke and
characteristics of toxic and carcinogenic componenets
as alluded to in some work from Lebanon by Alan
Shihada cited in the original paper discussed here.
Mostafa K. Moahmed
Professor of Community Medicine
AinShams University Faculty of Medicine
Abbassia , Cairo, Egypt
Principal investigator
Egyptian Smoking Prevention Research institute ESPRI
Tel /fax Office 20-2-368-2774 / 368-6275/ 368-8400
Mobile 20-12-241-7933
email: ecgc@internetegypt.com
Dear Editor,
This is to comment on the following recently published study:...
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...
Would sildenafil (Viagra) or tadanafil (Cialis) ameliorate ED in men who smoke? Was use of these medications asked about in the study?
Norbert Hirschhorn MD
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 specificit...
Less Harmful cigarettes do exist, but the majority of the smoking public is unaware that they are available. Isn't it about time that our government establish an agency that would regulate all tobacco products? I have recently been made aware of a new company that makes a less harmful cigarette. The companies name is Wellstone Filters(lowertar.com), and they have a developed a special cigarette filter that is patented and...
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 a...
I read the article by Offen et al with great interest. It is an excellent elucidation of the concepts of ‘boycott,’ ‘buycott,’ and ‘perimetric.’ One opportunity for perimetric action not mentioned is the option each academic has to boycott and/or draw attention to universities and medical schools that accept tobacco industry funds or hold tobacco stock. (1) The converse is equally appropriate; ‘buycott’ centers that hav...
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...
While I'm delighted that these tobacco industry trial products of unproven merit continue to "taste like s__t" (-a reference to the RJR president's famous quote in "Barbarians at the Gate"), I hope that we'll not see much more of OSH's time spent on what amounts mostly to market research valuable to the tobacco malefactors.
I certainly agree with most of the comments of Dr Kamal Chaouachi but the need to develop one generic name for the different types of this form of tobacco smoking is definite and we tend to prefer the term water- pipe smoking as it denotes the similarity that links all these forms and shapes and local names. Certainly these different names are associated with local geographical languages and idenified best in the reps...
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