Ethics of ““Waterpipe”” Antismoking Research and Suggested Guidelines

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We had recently criticised the numerous errors to be found in an alarmist paper on cancer authored by Drs Fouad FOUAD, Samer RASTAM and Ala-Eddin AL-MOUSTAFA, researchers affiliated to the US funded antismoking Syrian Centre for Tobacco Studies (US-SCTS). The authors’ response poses three ethical problems.[

1][2] First, evidence from their own sources show that, contrary to their denegation, they actually attended the 14thworld anti-tobacco conference in India (March 2009). Second, their renewed emphasis on the higher levels of nicotine in hookah smoke (vs.cigarette) is refuted by the findings of one member of their very US-SCTS team. Third, they ignored that our last Letter was signed by two scientists and concluded theirs by an ad hominem attack depicting one of its authors as a mere “comment” writer when the available literature shows that he has actually carried on the most extensive original research on this issue.

POINT 1: The 14th world anti-tobacco conference (Bombay, 2009)

The US-SCTS authors state that, because they “did not attend [the] conference”, they “didn’t have the chance to read [the] data” of a German study on human subjects we had cited in our previous critique [

2][3]. We pointed out that the negative results of the latter are in agreement with almost all studies on the relation between hookah smoking and cancer [2][3][4]. Astoundingly, Dr Rastam was actually part of a delegation from the US-SCTS (Kenneth Ward, Wasim Maziak, Thomas Eissenberg) to that conference and delivered a speech on the same day (9 Mar 2009), in the same room (Trident, Gulmohar) and during the same ““waterpipe”” session (from 15.30 to 16:30 hrs) as their German counterparts. The abstracts of both the German and US-Syrian delegations and the audio-visual presentations of their work are also available online [3][5]. Unless they boycotted each other, we remain very perplex by such a denegation. The data provided by the German study are very clear regarding carcinogens despite the fact that, because of a not less surprising statement highlighted in our previous letter, the German speaker (Dr Schulz) voluntarily refrained from detailing all the unexpected negative results because [3].

POINT 2: Nicotine in Hookah smoke

We will leave aside the question of tar that was already discussed (in relation to its different nature and glycerol component in particular) and the uncritical belief, among antismoking researchers, in the merits of the smoking machine designed by Shihadeh and Saleh at the US-American University of Beirut (US-AUB). According to the US-SCTS authors, this machine would show that hookah use “leads to a much higher yield” of nicotine. Unfortunately, on the one hand, this machine and its underlying “topography” has been criticised in detail [

2][6]. On the other, in a recent study (not the first one on this issue and not empty of biases) involving human subjects in a laboratory and carried out by a member of the US-SCTS and another from the US-AUB, the mean blood nicotine level in hookah smokers sitting for a 45 min session was lower than that found in cigarette users after having smoked a single cigarette [7]. Consequently, Dr Al-Moustafa et al’s argument about nicotine is refuted by their own colleagues. Unfortunately, this kind of serious error is very frequent in the ““waterpipe”” mainstream literature as other recent examples show [8][9]. Furthermore, the same study on blood nicotine gives credit to the critique of the smoking machine cited by the US-SCTS authors [6][7]. For instance, by contrast with the unrealistic inter-puff time (17s) of the US-AUB smoking machine, an average of 43s was found for this important parameter in a situation closer to real smoking. This huge difference in the smoking “pace” has not less dramatic consequences on the levels of tar (for which the percentage of glycerol should also be disclosed and not brushed aside).

POINT 3: “Comments”vs.“original research”

Resorting to an ad hominem attack is not very elegant particularly when it comes from world cancer specialists. Contrary to their recommendation (to focus on “original research”), we think that comments on other’s serious errors -repeated over the years in numerous scientific journals (particularly about lung, oral and bladder cancer)- should be disclosed. We also consider that both activities (correcting errors and doing original research) should not be construed as separate processes (

*). Unfortunately, this has actually been the case for almost one decade now. Year 2002 was recently considered by Wasim Maziak, the director of the US-SCTS, as the official commencement date for research in this field [10]. Interestingly, this date concurs with the inception of his centre. It was also decided that such a research would bear a label: ““waterpipe”” [11]. Then, the US-SCTS authors gloss over the fact that doing more “original research” requires direct or indirect funding, particularly from the pharmaceutical industry. Unfortunately, when a researcher, in contrast with those of the US-SCTS and US-AUB, has no preconceived idea of what the findings of a new study will be (e.g.: does not “firmly believe” that hookah causes lung, oral or pancreatic cancer, or that that 1 hookah equals 200 cigarettes), it is virtually impossible to get any funding, particularly from pharmaceutical industry-sponsored institutions interested in offering their nicotine “replacement” tools and products to quitting smokers. This is even more true if the same researcher states that public health decisions (sometimes translated in coercive laws) should rely exclusively on sound independent expertise and science [12]. Any scientist, particularly in a field like cancer research, is accountable for what (s)he publishes.

Suggested guidelines for sound research on hookah smoking

Given the high degree of international confusion, what is needed to soundly assess cancer risks among hookah (shisha, narghile, “water pipe”) tobacco users may be summarised in the following guidelines:

1-Respect the diversity of approaches to the problem although, as a recent publication by the American Cancer Society relevantly stressed, there is a need for skills that are wide-ranging and multi-disciplinary [13].

2-Avoid publication bias (bibliographical bias) [11]. This is so easy and, because hookah smoking has a strong socio-anthropological dimension, the “ethnic bias” -as Richard Horton described it one day [14]- will also be circled by the same token. Indeed, we were surprised that the work done by highly knowledgeable scholars in Saudi Arabia was not mentioned [11]. Among the latter, Tandon et al. reported that lung cancer was exceptionally uncommon in the southern part of their country, bringing out the historical and peculiar use of shisha. They added that there was no doubt that cigarette smoking, as a new trend, should be further reflected in lung cancer incidence [15]. Furthermore, the unavoidable first aetiological study on hookah smoking and cancer was dismissed by the US-SCTS authors [4]. This is even more inexplicable that it also contained a critical review of the world literature on hookah and cancer which shows that not a single study supports the high cancer risks raised with such a great confidence (“we firmly believe”) by the US-SCTS authors. While we have done work at the molecular level on human subjects, we note that the US-SCTS authors exclusively rely on the yields produced by a smoking machine designed by their colleagues of the US-AUB which has been criticised in detail for its serious flaws [6]. While we have recently published a critical complement in the British Dental Journal, we also found incomprehensible that pioneers such as Wynder, Hoffman, Roffo, Sanghvi and the authors of the US Surgeon General report were not cited [11].

3-Cite key studies for what they say, not the opposite of their findings (particularly about cancer risks) [11].For example, in a recent review, the US-SCTS and US-AUB researchers have cited our study on hookah smoking and cancer [4][16].Amazingly, they selected the findings related to heavy smokers and discarded those about medium and light smokers. This choice was even more irrelevant that the two latter’s profiles are much more akin to those of the US-American users of the modern hookah.

4-Do not cite studies which contain serious errors as those highlighted in our first Letter [2]. If necessary, cite them by highlighting their flaws. The bottom line is that there is unfortunately no Gospel Truth in this field [17].

5-Avoid tricky unethical situations when experimenting on human subjects [18].

6-Keep modest and avoid hasty announcements [19].


(*)Note about Dr Chaouachi’s research in response to the US-SCTS’ concern. He is the author or co-author of a 420 page transdisciplinary comprehensive doctoral thesis based on field research in Asia in Africa (including the first interviews with hookah smokers and the first review ever performed on the corresponding biomedical studies); two 250 page research books; the first aetiological studies on hookah smoking and cancer; the first study on radiological hazards of a variety of hookah smoking products; other critical pioneering reviews of the literature on many aspects (Environmental Tobacco Smoke in particular); a detailed critique of one of two WHO erroneous reports and of the US-AUB smoking machine which served as the basis for the former; pioneering measurements of expired and ambient CO and public health recommendations long before the inception date of the US-SCTS; etc. Whether the US-SCTS authors consider this as mere “comments” is their problem. Furthermore, independent researchers have now clarified the source of the international confusion and the fact that such a literature has been pirated must have some relation with its scientific content [20][21][22].



[1] Al-Moustafa AE, Fouad FM, Rastam S. Reply to the letter to the editor by Chaouachi & Sajid: World available evidence on cancer risk associated with hookah (shisha, narghile) tobacco smoking remains weak. Int J Cancer. 2010 Jan 20. [Epub ahead of print]

[2] Chaouachi K, Sajid KM. Cancer risks of hookah (shisha, narghile) tobacco use require further sound independent studies. Int J Cancer. 2010 Jan 20. [Epub ahead of print]

[3] Schulz T, Dettbarn G, Völkel W, Hahn J. Water pipe smoking: Biomarkers of exposure. Audiovisual presentation at 14th World Congress on Tobacco or Health (WCTOH), Bombay, 9 Mar 2009. Time: 15.30 – 16:30 hrs; Venue: Trident – Gulmohar.



Main file:

[4] Sajid KM, Chaouachi K, Mahmood R. Hookah smoking and cancer. Carcinoembryonic Antigen (CEA) levels in exclusive/ever hookah smokers. Harm Reduct J 2008 24 May;5(19). doi:10.1186/1477-7517-5-19

[5] Rastam S, Ward K, Maziak W, Eissenberg T. Subjective Measures, Puff Topography, and Exposure to CO in Waterpipe Users.Audiovisual presentation at 14th World Congress on Tobacco or Health (WCTOH), Bombay, 9 Mar 2009. 9 Mar 2009. Time: 15.30 – 16:30 hrs; Venue: Trident – Gulmohar.

Participants of the session:


Main file:

[6] Chaouachi K. Public health intervention for narghile (hookah, shisha) use requires a radical critique of the related “standardised” smoking machine. Journal of Public Health [Springer Berlin/Heidelberg] 2009; 17(5): 355-9. Doi: 10.1007/s10389-009-0272-7.

[7] Eissenberg T, Shihadeh A. Waterpipe tobacco and cigarette smoking direct comparison of toxicant exposure. Am J Prev Med. 2009 Dec;37(6):518-23.

[8] Chaouachi K. [E-Letter to the Editor] Errors in the scenario for the narghile epidemic in Syria. BMC Public Health 2007 (30 Dec).

[9] Chaouachi K. [E-Letter to the Editor] Hookah Smoking Harmfulness : Correcting a Few Errors and Clarifying Some Points of Interest. Tob Induc Dis. 2010 (20 Jan).

[10] Kozlowski, Kim. Michigan health leaders target growing hookah use. The Detroit News 2009 (Friday, Aug 14)

[11] Chaouachi K, Sajid KM. A critique of recent hypotheses on oral (and lung) cancer induced by water pipe (hookah, shisha, narghile) tobacco smoking. Med Hypotheses 2009 (online: 24 Dec). doi:10.1016/j.mehy.2009.11.036

[12] Molimard R. Le rapport Européen Lifting the SmokeScreen: Etude épidémiologique ou manipulation ? [The European Report “Lifting the SmokeScreen”: Epidemiological study or manipulation?] Rev Epidemiol Sante Publique. 2008 Aug;56(4):286-90. [in French. Abstract in English] [English version]

[13] Glynn T, Seffrin JR, Brawley OW, Grey N, Ross H. The globalization of tobacco use: 21 challenges for the 21st century. CA Cancer J Clin 2010;60;50-61.

[14] Horton R. Medical journals: evidence of bias against the diseases of poverty. Lancet. 2003 Mar 1;361(9359):712-3.

[15] Tandon P, Pathak VP, Zaheer A, Chatterjee A, Walford N. Cancer in the Gizan province of Saudi Arabia: an eleven year study. Ann Saudi Med 1995;15(1):14-20.

[16] Cobb C, Ward KD, Maziak W, Shihadeh AL, Eissenberg T. Waterpipe tobacco smoking: an emerging health crisis in the United States. Am J Health Behav. 2010 May-Jun;34(3):275-85.

[17] Hayreh SS. Scientific literature and gospel truth. Indian J Ophthalmol. 2000 Jun;48(2):93-9.

[18] Chaouachi K. Hookah (shisha, narghile, “water pipe”) indoor air contamination in German unrealistic experiment. Serious methodological bias and ethical concern. Food Chem Toxicol 2010;48(3):992-5. Doi:10.1016/j.fct.2010.01.020

[19] Molimard R. Suppression du tabac dans les lieux publics: la presse trop pressée ? [Tobacco quelling in public places: journals too much in a hurry?] Réalités Cardiologiques 2008; 247 (Jun):3-4.

[20] Ben Saad H. Le narguilé et ses effets sur la santé. Partie I : le narguilé, description générale et propriétés [The narghile and its effects on health. Part I: The narghile, general description and properties]. Rev Pneumol Clin 2009 65: 369 [Epub ahead of print 6 Nov]. Doi : 10.1016/j.pneumo.2009.08.010

[21] Ben Saad H. Le narguilé et ses effets sur la santé. Partie II : les effets du narguilé sur la santé [The narghile and its effects on health. Part II: The effects of the narghile on health]. Rev Pneumol Clin 2009 [Epub ahead of print 6 Nov]. Doi : 10.1016/j.pneumo.2009.08.011

[22] Chaouachi K. An open letter against plagiarism and plagiarists. Tabaccologia 2009; 1: 46-7.