RT Journal Article SR Electronic T1 Toxicant inhalation among singleton waterpipe tobacco users in natural settings JF Tobacco Control JO Tob Control FD BMJ Publishing Group Ltd SP 181 OP 188 DO 10.1136/tobaccocontrol-2017-054230 VO 28 IS 2 A1 Jawad, Mohammed A1 Eissenberg, Thomas A1 Salman, Rola A1 Soule, Eric A1 Alzoubi, Karem H A1 Khabour, Omar F A1 Karaoghlanian, Nareg A1 Baalbaki, Rima A1 El Hage, Rachel A1 Saliba, Najat A A1 Shihadeh, Alan YR 2019 UL http://tobaccocontrol.bmj.com/content/28/2/181.abstract AB 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.