Jordanian Study on Narghile (Hookah, Shisha) Tobacco Smoking

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[Snapshot of the top of the web page taken by “Bing” search engine on 20 Nov 2010. The actual censored text was available for several months as below:]


While Dr Naja Dar-Odeh and her colleagues in Jordan emphasise the global nature of the shisha «epidemic»[1], they use here and there the «Eastern Mediterranean Region» (EMR) phrase. One may ask: Is not the «Western Mediterranean Region» (Libya, Tunisia, etc.) also affected by the shisha “epidemic” that the authors describe as global… Obviously there is a serious contradiction.

This is not a mere linguistic or geographical detail as the same error appeared recently again in other publications on this issue [2][3][4]. Shisha smoking has been a centuries-old tradition in many other regions of the world than the EMR, particularly in Africa and Asia. The geographical distribution of shisha use is something and the recent antismoking research (mainly led by the US-Syrian Centre for Tobacco Studies [US-SCTS] and the US-American University of Beirut [US-AUB] ), certainly based in the “Eastern Mediterranean”, is something else…


Dar-Odeh and her colleagues acknowledge the existence of a so-called «controversy associated with potential health hazards of narghile» although, and quite amazingly, no further detail is given on such an important notice. The scientific method implies that whenever a «controversy» arises somewhere, its terms be clearly posed. Certainly, the first party in this «controversy» can be easily identified from Dar-Odeh et al’s bibliographical references [1]; mainly the production of the afore-mentioned US-SCTS and US-AUB ««waterpipe»» antismoking centres.

For the sake of a sound scientific debate, the authors should have made the choice of either identifying each of both parties in the so-called scientific “controversy” or none of them. This is even more true in view of the striking unbalance of forces (search PubMed, Embase, ISI Web of Science, etc. for the related literature)[5].

Indeed, when supposedly reviewing the literature on diseases related to shisha smoking, why did not Dar-Odeh et al cite the most original and popular study on hookah smoking and cancer carried out on human exclusive smokers (and not on a biased smoking machine [6]) published in this very journal (Harm Reduction Journal), and viewed dozens of thousand times so far [7] ? Because of its «unexpected» “negative” results (highlighting, in particular, a dose-response relationship) ?

With no concrete evidence (except a narrow selection of confusing studies, Dar Odeh et al once again hype the cancer risks associated with shisha smoking [1][8]. The error about mentioning bladder cancer is in fact a direct consequence of a “review” authored by the US-SCTS [9] whose errors have been highlighted elsewhere in the critical peer-reviewed literature [5][7]. A recent clarification showing the source of the international confusion about the bladder cancer risk has been recently published [10].

Even Al-Safi et al, a team who has led in Jordan (the very country of the authors) an important original fact-finding study involving a large sample of volunteers, has not been cited by Dar-Odeh et al. Is this, once again, because of its “unexpected” “negative” findings related to blood pressure and heart rate among shisha smokers [11][12] ?

To close this discussion on publication bias, we would like to draw the attention of readers to the fact that, astoundingly, in the long list of antismoking publications on shisha smoking (««waterpipe»»), glycerol and dihydrogen monoxide are never mentioned.

Yet, shisha smoke, unlike that of regular cigarettes, is mainly made up of these two components [5] ?

Are the latter taboo issues ? Who of both parties is living in Wonderland if we may refer to a highly-cited one-page article published in The Lancet: narghile users or «« waterpipe»» researchers [13][14]?


Dar-Odeh et al state that “interestingly, a substantial proportion of students (89%) thought that narghile is less harmful than cigarettes, in contrast to their peers in a neighboring country”. The reason is very simple as the population of that country (Syria) has been submitted to continuous “public health” campaigns (targetting ««waterpipe»» in particular) fed by the US-SCTS located in that country since 2002. This did not happen in Dar-Odeh et al’s country.

In any case and on a global scale, how can one seriously «assess [individuals] beliefs about narghile’s adverse health consequences» in the context of a world actions against tobacco smoking ? Intensive press campaigns (as the one against shisha smoking) exclusively supported by interviews with «« waterpipe»» antismoking experts (no confrontation of viewpoints at all) are certainly known for their “brainwashing” effect. We are afraid these are artifacts, not sound science… However, a backlash effect is that such communication techniques eventually discredit science and, beyond, public heath interventions.

In this respect, one of the reasons of the world shisha epidemic (never mentioned by antismoking researchers for obvious reasons) is a “boomerang” effect of the vehement cigarette antismoking campaigns of the Eighties and Nineties (see our doctoral thesis, fruit of early transdisciplinary research between years 1995 and 2000). Today, another factor that may push more and more individuals to indulge in shisha smoking is the growing body of flawed and biased evidence represented by the great majority of «« waterpipe»» publications [5].


When comparing aldehydes yields in cigarettes and narghile, Dar-Odeh et al refer to «one session of narghile smoking» without revealing a very important “detail”: that the measures were not performed on real human smokers but produced by a biased smoking machine [1][5][6].


Since Jordanian non-smoking students apparently brush more their teeth than their narghile smoking peers, Dar-Odeh et al’ findings remain, in our opinion, of low interest [1].Tobacco smoking is a hazardous behaviour and the job of tobacco researchers should be limited to objectively outline the corresponding health effects.

In their traditional aspect, hookahs have been around for centuries and have not posed any particular public health problem until year 2002, inception date of the «« waterpipe»» antismoking centres [5]. Unsurprisingly one year later, the world antismoking Conference on Tobacco or Health held in Helsinki issued concerns in this respect. One great unanswered question is “Why ?”. In a recent extensive critical review, an independent lung specialist and physiologist has recently stressed that we have reached a high degree of international confusion in this field [15]. As for us, we believe that it is definitely time to make tabula rasa of research on this issue [16]. Simply, as in other fields of biomedical research, there is no Gospel Truth [17].



[1] Dar-Odeh N et al. Narghile (water pipe) smoking among university students in Jordan: prevalence, pattern and beliefs. Harm Reduction Journal 2010, 7:10. Doi:10.1186/1477-7517-7-10

[2] Harrabi I, Maaloul JM, Gaha R, Kebaili R, Maziak W, Ghannem H. Comparison of Cigarette and Waterpipe smoking among pupils in the urban area of Sousse, Tunisia. Tunis Med. 2010 Jul;88(7):470-3.

[3] Akl E, Gaddam S, Gunukula SK, Honeine R, Abou Jaoude P, Irani J. The effects of waterpipe tobacco smoking on health outcomes: a systematic review. International Journal of Epidemiology. Advance Access published online on March 4, 2010. Doi:10.1093/ije/dyq002

[4] Chaouachi K. [Comment] “Systematic Reviews” on ““Waterpipe”” (Shisha, Hookah, Narghile) Tobacco Smoking Should Not Recycle Old Errors. BMC Public Health 2010 (13 Aug).

[5] 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 2010; 74: 843–6. Doi:10.1016/j.mehy.2009.11.036

[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] 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)

[8] Chaouachi K. Hookah epidemic [Clarification about Cancer]. Br Dent J 2009; 207: 192-3. Doi: 10.1038/sj.bdj.2009.771

[9] 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.

[10] Chaouachi K. Clarification about bladder cancer and shisha smoking in Egypt. Cancer Epidemiology (The International Journal of Cancer Epidemiology, Detection, and Prevention) 2010; 34: 220. Doi: 10.1016/j.canep.2010.01.001

[11] Al-Safi SA, Ayoub NM, Albalas MA, Al-Doghim I, Aboul-Enein FH. Does shisha smoking affect blood pressure and heart rate ? J Public Health 2009; 17:121–126.

[12] Chaouachi K. Errors and misquotations in the study of shisha, blood pressure and heart rate in Jordan. Journal of Public Health [Springer Berlin/Heidelberg] 2009 (21 Feb);Online First

[13] Kandela P. Narg[h]ile smoking keeps Arabs in Wonderland. The Lancet 2000; 356 (9236):1175

[14] Chaouachi K. Narghile smoking keeps researchers in Wonderland. J Bras Pneumol. 2009Aug;35(8):819-20.

[15] 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 Dec;65(6):369-75. Doi : 10.1016/j.pneumo.2009.08.010

[16] Chaouachi K. [Comment] Time to Make Tabula Rasa of Some Misconceptions in Research on Hookah (Narghile, Shisha) Tobacco Smoking. Tobacco Induced Diseases 2010 (2 Jul)

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

Competing interests