Pregnant Women in Iran and Environmental Tobacco Smoke

The first world poem about smoking is Iranian (1535) and it is a poem of love:”Your lips make qalyân draw enjoyment. Its mouthpiece becomes like a sweet. This is not smoke around your face. But a cloud whirling around the moon…” Source: Semsar H., cited in K.C.’s book (1997)[16]***************************************** ABBREVIATIONS. EMSS : Exhaled Main-Stream Smoke; ETS : Environmental Tobacco Smoke (taken as synonym of SHS); MSS : Main-Stream Smoke ; SHS : Second Hand Smoke (syn. ETS); SSS : Side-Stream Smoke. Introduction : In reply to a previous paper by Dr Mirahmadizadeh and Dr Nakhaee ( M&N )’s raising concern over local water pipes’ Environmental Tobacco Smoke (ETS), a Letter to the Editor was sent to the journal and accepted[1][2]. Its objective was only to suggest a forgotten reference found to be relevant (at least from a bibliographical viewpoint) to pregnancy and hookah (narghile, shisha, goza, qalyân) passive smoking. It was felt even more useful that it came from the very Middle East[3]. The Letter and M&N’s reply[4]took almost one year to get published so, in view of the level of confusion and in order to spare time, it was decided to expedite the matter by addressing M&N’ arguments here in the form of a KNOL. M&N are perfectly right to stress that extrapolating results from animal studies to humans should be done with caution. However, they quote themselves from a study that they have apparently not read (they cite a WHO report) according to which “the concentration of various inflammatory mediators in plasma and pulmonary secretions of rabbits was significantly higher in animals exposed to water pipe smoke compared to controls[5][6]. M&N did not realise in such a study that would document “the health hazards of passive water pipe (type not specified) smoking”[6], the rabbits had been exposed to the local water pipe MainStream Smoke (MSS), that is the smoke drawn from the hose, not the one exhaled by a human subject, named Exhaled MainStream Smoke (EMSS). This means that the rabbits had not been exposed to the local water pipe ETS (“passive smoke”) but to a precursor of it, MSS[7]. The case is different from cigarettes, hence the huge confusion. Indeed, cigarette ETS is a combination of aged and diluted Side-Stream Smoke (SSS) and EMSS[7]. By a striking contrast, water pipe ETS is mainly made up of EMSS because, as emphasised before, the SSS component is almost inexistent, as acknowledged by M&N themselves[4]. Consequently, the physiological damage highlighted by M&N, if any, would be an effect of water pipe MSS, not EMSS and therefore, not its ETS. The same for Sulaiman’ study on rats which were exposed to a machine-activated shisha smoke. We wished M&N had noted this point instead of rambling. This researcher found that passive exposure to the smoke of the local pipe (shisha) during pregnancy had no effects on the gestational period, number of pups, birth weight, and body weight growth[3]. Since it was MSS, a precursor of EMSS, it is assumed that the latter has even less important related effects…

Qalyan, XVII ^th century

“Passive exposure” is equivalent to “passive smoking” or exposure to ETS when it comes to cigarettes because the cigarette is known to generate, by itself, SSS. By contrast, and since this last component is almost inexistent in water pipes, it is wrong to name “passive smoking” the action of subjecting animals to water pipe smoke. The animals are in fact exposed to its MSS, i.e. the smoke drawn from its hose. In order to test the effects of water pipe ETS on an animal, researchers should get, in a way or another, EMSS (through the use of an artificial lung for instance)[8][9]. Certainly, Baker and Dixon’ statement that ‘‘on average, 60–80% of the mainstream smoke particulate matter is retained in the lungs after inhalation’’ is about cigarette smoke[9]. This fact was recalled and is even more relevant to hookah smoke that the latter is much less complex than cigarette smoke. Indeed, only 142 chemical compounds were detected in a shisha filled with jurak (a mixture of 15% of tobacco leaves and 47% carbohydrates (glucose)). This figure can be compared with the 4,700 substances identified so far in cigarette smoke (exhaustively reviewed in[7]). Certainly “respiratory tract retention” depends on inhaling patterns (i.e., depth and duration of inhalation, hold time in the lungs, among others) among cigarette smokers. This is why Baker and Dixon gave an average percentage. Only recently, pioneering studies carried out on cigarette MSS vs. EMSS showed that many compounds (from PAH to aldehydes and phenols) are ‘‘respiratory tract filtered’’ to a very large extent (exhaustively reviewed in [ 7 ]). Suggesting to extrapolate these results to hookah smoking is even more relevant that, let us ask: what will be result of respiratory tract filtering of a (tobacco and molasses) smoke mainly made up (up to 80%) of glycerol and DiHydrogen Monoxide ?[7]Unless the latter substance is really that hazardous to human health even in tiny quantities…[10]As for the “large amounts of second-hand smoke particles indoors” (citing as study by Monn et al.[11][12]), this is another point of huge confusion as these authors’ study was about MSS only. Besides, what the corresponding experiment has shown is that hookah MSS is much less concentrated in fine particles and CO than cigarette smoke[7]. As for Maziak et al. (2008)[12], cited by M&N, it was based on a biased comparison between cigarette (smoke for only a few minutes) and hookah smoking (smoked over 35 minutes) and even matched a light cigarette (know to produce less particles) to the hookah. These are great biases highlighted in the comprehensive critical review on this issue: “Consequently, it appears that hookah smoke in this experiment [i.e. Maziak et al] was in fact 6.4 and 3.5 times less concentrated than cigarette smoke in, respectively, PM10 and PM2.5”[7]. In these conditions, there is absolutely no need to alert on the “critical importance of secondhand water pipe smoke” and hyperbolise its hazards. Let us focus, as with cigarettes, on those of active smoking. There are already great differences between cigarette active (MSS) and passive smoking (mainly due to SSS). This is even more true for hookah in which passive smoke is mostly made up of EMSS. Since most of the (strongly biased) studies that have been raising potential hazards of cigarette passive smoking refer to its SSS, it is amazing to see that a device known for not generating almost no SSS is presented by scientists as huge danger because of its EMSS. It is hoped that the authors will understand that what, in the end, may “unwantedly lead to more widespread use” of hookahs[4]is the systematic forbidden debate over these questions (in agreement with an unjustified prohibitionist agenda for the world) and the publication of pseudo-scientific reports.[ ADDENDUM ] After the claims about the supposedly high hazards of hookah Environmental Tobacco smoke. have been clarified[7], findings from antismoking researchers funded by powerful lobbies have been published. However, they were actually based on methodological tricks[13][14]. Interestingly, in a recently published study, an Iranian team led by Dr Ghasemi did not deem it necessary to map hookah passive smokers[15]. There must be some reason…

Iranis folding under Western anti-tobacco pressure (Daily Newspaper, 29 May 2005)

[ ADDENDUM 31 March 2010 ] The World Health Organisation (WHO) has not complied with its obligations regarding the use of shisha by pregnant women. In spite of the existing evidence (*), particularly the high CO (Carbon Monoxide) levels in hookah smoke, we have seen no explicit harm reduction recommendation or public warning […] In these conditions, […] we, once again, take the historic responsibility of advising pregnant women to avoid smoking during the corresponding period” (cont. on theWomen section the Hookah F.A.Q.). Tobacco is dangerous. Let us not make research on it more hazardous.

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