This article shows that biomedical ethics is not universal as so-called “prestigious” biomedical journals and publishing groups claim. When it comes to ““waterpipe”” (hookah, narghile, shisha) antismoking research, all ethics seems meaningless.
The would-be reason is that hookah, unlike cigarettes, is viewed (more and more with a xenophobic bias) as a non-European or non-US “product” despite the fact that many reports show that the youth of these last regions are particularly keen on learning more about the socio-cultural context of shisha smoking.
From there, all “slips” have been permitted (in a way very similar to the present war in the Mediterranean – the methods are always the same…). Among others:
-the most unscientific groundless statements (comparisons between hookah and cigarette smoke in particular) may be published in “high impact-factor” scientific journals boasting of being ““peer-reviewed””;
-whistle blowing on undisclosed conflicts of interests involving the pharmaceutical industry and even the tobacco industry are systematically silenced and swept under the carpet (“we do not consider there is a problem” – see further down).
First draft (25 March 2011)
Half a century back, Dr Badri Raj Pande lamented the arrival of cigarettes in his country (Nepal):
“I wonder how these representatives of the tobacco industry manage to reach the almost inaccessible hilly regions in this country”?[*]
[*] Hubble-bubble Smoking. BMJ 1962 Jun 2: 1556. Cited in: Chaouachi K. Prevention and sporadic carbon monoxide poisoning related to shisha (hookah, narghile) tobacco smoking. J Emerg Med. 2010 (Feb 2). Doi:10.1016/j.jemermed.2009.11.027)
The pharmaceutical Industry(sometimes dubbed Big Pharma) represents those companies (pharmaceutical laboratories) which market nicotine “replacement“ therapies and products (nicotine gums, inhalers and patches and medicines such as Chantix/varenicline, Zyban/bupropion, etc.). It is believed that it currently funds, directly or indirectly, 80% of biomedical studies on smoking.
The Tobacco Industry(sometimes dubbed Big Tobacco) represents those companies which manufacture cigarettes and generally not hookah and the related products (moassel/flavoured tobacco molasses).
The case outlined in this article shows why and how:
-the pharmaceutical industry may consider hookah (shisha, narghile) smoking as an embarrassing “outsider”. In other words, cigarette addicts are easier to target and “treat” than hookah recreational users… This would explain why most of the one hundred ““waterpipe””-coded articles published since year 2002 are funded, directly or indirectly, by this industry.
-the tobacco industry obviously views hookahs as an embarrassing economic bubbling “rival”. If cigarette smokers switch to its use, then this is a market loss.
(*).If a teenager first indulges in tobacco smoking through hookah use, then this is another loss even more fatal than it is likely (for many pharmacological, psychological, social, cultural, etc, factors) that this user will tend to avoid cigarette smoking even when the pipes are not available anymore. It is noteworthy that, unlike the other industry, the tobacco industry has not produced, through its rich history, a single study on hookah smoking…
(*)In their ””book”” (plagiarism: see Knol ” Du plagiat au Métaplagiat ” [Plagiarism & Metaplagiarism], Bertrand Dautzenberg (Chairman Office Français du Tabagisme) and Jean-Yves Nau (columnist withLe Mondedaily newspaper and the Revue Médicale Suisse) warn that“the great risk is that shisha, progressively, take the place of cigarettes”(page 58). A “great risk” for whom ?
The Opinion of Dr Siegel, an Independent External Observer
Dr Michael Siegel, a worldwide renowned independent (from both the pharmaceutical and tobacco industries) tobacco control researcher, has recently published on his popular site an
Dishonest Disclosures? Six Articles on Health Effects of Hookah Use Fail to Mention that Research Sponsor Was Directed by a Tobacco Industry Executive(10 Mar 2010)
“Revelations regarding IDRC Chairperson Barbara McDougall’s unfortunate ties to the tobacco industry were not known to the authors of this study at the time it was funded and executed. Strangely, however, the papers still state: “All other authors declare that they have no conflicts of interest. ”
I don’t understand how they can make this statement […] For example, in the very decisions about what research to fund in the first place, having a tobacco industry executive as the Chair of the Board may influence those decisions . Studying hookah use seems to be a wise decision for a tobacco company Chair because it would help deflect attention of her products and put them onto hookah, a potential competitor. ”
“I believe that when a researcher accepts funding from an organization, it is incumbent upon the researcher to understandwho he or she is taking money from .”
“It is important to point out that conflicts of interest are important not only in research that denies the health effects of tobacco products. Conflicts of interest are important in all research, even if it is reporting that tobacco use is harmful. ”
The above article is only critical of one thing: the failure, by the authors of ““waterpipe””-coded studies, to disclose the link of the whole span of their work to the Tobacco Industry, particularly after they have been informed of these ties. Consequently, we realise that we are not the only ones who do ask relevant questions when it comes to hookah (shisha, narghile) smoking.
Unlike the above researcher, we are nonetheless more interested in
the scientific and unscientific contents of these publications.Although it is necessary, we do not like very much this “job” of alerting the world (“whistle blowing”) on undeclared conflicts of interests. However, the scientific misconduct has reached very high proportions this time.
We have witnessed a common intent -on behalf of the ““waterpipe”” researchers themselves; the journals in which they have published their antismoking literature and; the publishing groups of these journals-, to simultaneously “sweep under the carpet” the exposed ties of antismoking research to the tobacco industry. This is even more embarrassing that some authors involved in this scandal are members of the
Globalink network, supposed to be a champion of the fight against the tobacco industry…
The publishers and journals in which these articles (and others) appeared are, namely:
-the ELSEVIER group for both the Atmospheric Environment journal (1 article authored by the US-American University of Beirut)[
-the ELSEVIER group, again, for the Food & Chemical Toxicology journal (4 studies by the US-AUB)[
-the INFORMA HEALTHCARE group for the Inhalation Toxicology journal (1 study by the US-AUB)[
What the Involved Publishing Groups Have Responded
We deemed it a waste of time to contact the Editors of these journals for some solid reasons. First of all, it appears that the authors had decided to “sweep under the carpet” their exposed undisclosed conflict of interest with the Tobacco Industry. The normal and most honest process would have been for the authors (Alan Shihadeh, in particular who is supervising the bulk of the ““waterpipe”” antismoking literature at the US-AUB) to inform the Editors that a correction needed to be published, as a form of respect of the readership. This has never been done.
The other reasons appear below as the same articles (generally hyping the hazards of hookah smoking according to a world prohibitionist agenda) were also stained with serious methodological errors.
1-The US-AUB article funded by the Tobacco Industry and published in the ATMOSPHERIC ENVIRONMENT journal (ELSEVIER publish group) with undisclosed conflicts of interests
One of our previous Knol articles shows that the Atmospheric Environment journal had previously trodden the editorial ethics it boasts of adhering to by dismissing, on no scientific ground, our critique of their highly politicised prohibitionist (regarding the United Kingdom Ban on smoking, in particular) paper by Nancy Daher, Alan Shihadeh et al [
14]. Interestingly, we emphasised that this journal is published at the University of East Anglia (United Kingdom), whose Climate Unit is known for a similar scandal regarding the dismissal of dissenting views on behalf of researchers opposed to the “orthodox” views in relation to climate change (See KnolWaterpipegate and Climategate ).
> In the name of the
Elsevier group , Ms Keall responded to our request for clarification by apparently dodging the issue:“if you would like to submit a full scientific manuscript to any of our journals we would consider this in the normal manner”…(7 Jan 2011)
2- The four US-AUB articles funded by the Tobacco Industry and published in the FOOD & CHEMICAL TOXICOLOGY journal (ELSEVIER publish group) with undisclosed conflicts of interests
This is not the first scandal related to this journal when it comes to ““waterpipe”” smoking. A German unrealistic experiment on hookah (shisha and narghile) environmental tobacco smoke (ETS) and charcoal emissions was once published in the Food and Chemical Toxicology journal. Serious methodological biases had been identified. Because it involved human subjects who had been exposed to highly hazardous conditions (no ventilation for four hours and exposure to non-natural charcoal still emitting by-products in its lighting phase), it also posed not less serious ethical problems (violation of the Declaration of Helsinki on the protection of human subjects in medical research). After almost one year, we eventually won the right to expose these ethical breaches in a critical article published in the same journal
In spite of the number of articles supported by the Tobacco Industry and for which no disclosure was published in that journal [
1], no correction was published.
> In the name of the
Elsevier group , Dr Perill responded to our request for clarification that “I have discussed your letter with the editors and we do not consider there is a problem , but appreciate your letter” (3 Mar 2011).
3-The US-AUB article funded by the Tobacco Industry and published in the INHALATION TOXICOLOGY journal (INFORMA HEALTHCARE GROUP), with undisclosed conflicts of interests
This is perhaps the greatest ethical scandal because it is multiple. Our critique of the US-AUB paper (by Marwan Katurji, Alan Shihadeh et al)[
13] was accepted by twice by Editor-in-Chief Donald Gardner (29 Nov and 01 Dec 2010) then suddenly rejected further to external pressures (in particular, lies from the authors and the so-called ““peer-reviewer””). The subsequent “justification” for such a U-turn decision was based on a “report” by the ““peer-reviewer”” who, not only proved that he had not read our manuscript but, also called to burning our books (lying about the actual mention of our books in the manuscript and considering the same books as conflicts of interest…).Details about this story that many will find incredible are available in anonline document (including the exchange of correspondence between the Editor-in-Chief and us).
In his article, Dr Siegel did not include this US-AUBpaper in which one can read:
“This study was supported by grants from the American University Research Board and Research for International Tobacco Control, a secretariat of the IDRC (Canada). The authors have no competing interests related to this work”. Their manuscript was received on 23 July 2010 by the Inhalation Toxicology journal.Certainly, this occurred a few months after Mrs. McDougall stepped down from her position within Imperial Tobacco (March 2010). In fact, this study (on in situ measurements) had been ongoing, with continuous RITC/IDRC funding since 2007. The authors themselves presented an abstract in 2007 at a meeting of the Society for Research on Nicotine Tobacco. The title was:“In situ carbon monoxide, “tar,” and topography measurements for 20 narghile waterpipe smokers in natural settings using a novel smoke sampling device”(available in a bulk file from here ).
> In the name of the
Informa Healthcare group , Mrs Kefi responded to our request for clarification that:
“In line with our strong disclosure policy and as members of the ICMJE , we will investigate these concerns thoroughly according to COPE guidance. This investigation will be led by the Managing Editor of the journal […]“(5 Jan 2011).
Without any experience of the extent of corruption in the tobacco control field, their first impression was that:
“[…]It is not the author’s responsibility to disclose the points you raised regarding RTIC and IDRC. The author’s declaration of interest regarding IDRC funding is appropriate and sufficient”(15 Mar 2011).
So, we decided to refer the Informa Healthcare group to Dr Siegel’ article so they can think over more thoroughly on their erroneous biased appreciation. The same goes for their evaluation of
Globalink as a mere “advocacy/regulatory group”. We stressed that thatGlobalink is absolutely not an “advocacy/regulatory group”. To take a modern example, it is something like “Facebook” where the four ““waterpipe”” antismoking authors (Alan Shihadeh, Wasim Maziak, Thomas Eissenberg, Kenneth Ward) have been advertising the kind of publications that have been criticised in detail for their serious flaws.
WHO (World Health Organisation) TobReg members and many other activists across the world are also affiliated with this organisation.The great majority of “peer-reviewers” to whom Editors of biomedical journals send manuscripts on tobacco smoking, are members of Globalink. Consequently, this is a universal conflict of interest that must be disclosed, even more if we are to stick to COPE guidelines (see Knol onGlobalink universal invisible conflict of interest ).
As it is reflected in our self-explanatory “whistle blowing” letter of last January:
Hookah, because of its very poor addictive potential, may represent an economic rival for the traditional cigarette market. Antismoking researchers or health activists’ repeated hyping of water pipe hazards [
10], not only have made “cigarettes almost look healthy by comparison” , but may have provided a commercial opportunity for the major tobacco internationals (including British American Tobacco, the parent organisation of Imperial Tobacco) in the Middle East region . […] The question may arise to how such studies may have served, directly or indirectly, the interests of those who would like hookah smokers -or potential hookah smokers- to remain in the cigarette market.
Because hookah (shisha, narghile) is viewed as a non-“Western” form of smoking, everything seems to be permitted as this ethical “double standard” shows. There would be ethical standards for the “West” and others for the “East”. This seems a valid assumption as evidence of xenophobic bias in the biomedical press (as far as shisha research is concerned) is cumulating (See our
Knol onBritish Medical Journal’s“Hookah Smoking Prophet “, a xenophobic article authored by Dr Liam Farrell).
COPY of “Whistle Blowing” Letter to the Publisher (ELSEVIER) of the Food & Chemical Toxicology journal
Note: the two other letters (sent to the publishers of the other journals) were similar in their structure and content.
To: Dr Perill, Publisher Food & Chemical Toxicology
From: Dr Kamal Chaouachi
Date: 03 January 2011
Letter to the Editor: “Undisclosed conflicts of interests in Canadian IDRC/RITC funded studies on narghile (hookah, shisha) tobacco smoking”
A series of studies published in the Food & Chemical Toxicology (FCT) journal mentioned no conflict of interest
. Its authors limited themselves to acknowledging the support from RITC (Research on International Tobacco Control), a branch of IDRC (International Development Research Centre, Canada). On one hand, the links of this organisation to pharmaceutical companies (such as Glaxo-Wellcome, Smith Kline Beecham and Merck-Frost – described as “strategic partners”) were perhaps deemed not relevant .
However, and on the other, IDRC’ ties to the tobacco industry (Imperial Tobacco)–through its very Chairperson, Ms Barbara McDougall, who took up her duties by January 2007 [
6]-, have never been acknowledged in FCT. Further to an early alert by April 2010, a Canadian antismoking medical journal had, two months later, published an editorial in this respect . The information has been circulated among the “tobacco control” world community since then.
Most recently, the former presence of IDRC Chairperson on the board of Imperial Tobacco were characterised as “unfortunate” in a paper authored by a US-Lebanese-Syrian antismoking team [
8]. The latter included Alan Shihadeh from the US-American University of Beirut (US-AUB), author or co-author of the four above-mentioned FCT studies. Two other co-authors of the publication behind the “revelations”(sic) are also affiliated with the US-AUB: Asma Bazzi and Ghazi Zaatari; the latter being simultaneously Chair of WHO TobReg (World Health Organisation “study group for the regulation of tobacco products”). The remaining co-authors are affiliated with the US-Syrian antismoking centre (Iman Ibrahim, Thomas Eissenberg, Wasim Maziak, Kenneth Ward, Samer Rastam).
These “revelations” actually occurred against the background of a world agenda characterised by more restrictions or bans on tobacco smoking in agreement with the so-called “Framework Convention for Tobacco Control”[
9]. In the same time, light flavoured tobacco-molasses hookah (narghile, shisha) smoking is now depicted as a world tobacco epidemic . Interestingly, RITC has actually funded a substantial series of publications on ““waterpipe””/narghile smoking. Most of them (if not all) were carried out in Lebanon by the US-AUB team and have exclusively focussed on narghile smoking. Amazingly, the prevalence of cigarette use in that country is much more higher (around 60%) and certainly less a recreational activity than narghile smoking.
Furthermore, the tobacco industry, unlike pharmaceutical companies, has always kept silent on this smoking method. In these conditions, it is reasonable to assume that that hookah, because of its very poor addictive potential, does represent an economic rival for its traditional cigarette market. Antismoking researchers or health activists’ repeated hyping of water pipe hazards [
10], not only have made “cigarettes almost look healthy by comparison” , but may have provided a commercial opportunity for the major tobacco internationals (including British American Tobacco, the parent organisation of Imperial Tobacco) in the Middle East region . Consequently, given that RITC/IDRC, as the funding source of a series of ““waterpipe”” articles published in FCT, has a relation with the tobacco industry, the absence of a disclosure of conflicts of interests poses a serious problem. The question may arise to how such studies may have served, directly or indirectly, the interests of those who would like hookah smokers -or potential hookah smokers- to remain in the cigarette market. In the same vein and notably, IDRC/RITC has also funded other similar ““waterpipe”” US-AUB publications, fraught with serious errors and biases, which appeared in other journals. One of them even states that it was supported by “a generous grant” from RITC .
 Al Rashidi M, Shihadeh A, Saliba NA. Volatile aldehydes in the mainstream smoke of the narghile waterpipe. Food Chem Toxicol. 2008 Nov;46(11):3546-9.
 Monzer B, Sepetdjian E, Saliba N, Shihadeh A. Charcoal emissions as a source of CO and carcinogenic PAH in mainstream narghile waterpipe smoke. Food Chem Toxicol. 2008 Sep;46(9):2991-5.
 Saleh R, Shihadeh A. Elevated toxicant yields with narghile waterpipes smoked using a plastic hose. Food Chem Toxicol. 2008 May;46(5):1461-6.
 Sepetdjian E, Shihadeh A, Saliba NA. Measurement of 16 polycyclic aromatic hydrocarbons in narghile waterpipe tobacco smoke. Food Chem Toxicol 2008 May;46(5):1582-90.
 RITC (Research on International Tobacco Control)
 IDRC (International Development Research Centre). Barbara McDougall Named Chair of IDRC’s Board. December 2007
 Hébert PC, Reddy KS, Jha P. Canada’s perceived lack of leadership on global tobacco control. CMAJ (Canadian Medical Association Journal) 2010; 182 (10). First published June 21, 2010. Doi:10.1503/cmaj.100850
 Maziak W, Rastam S, Shihadeh AL, Bazzi A, Ibrahim I, Zaatari GS, Ward KD, Eissenberg T. Nicotine exposure in daily waterpipe smokers and its relation to puff topography. Addict Behav. 2010 Dec 2. [Epub ahead of print]. Doi:10.1016/j.addbeh.2010.11.013
 WHO TobReg (World Health Organization “study group for the regulation of tobacco products”) and Framework Convention for Tobacco Control
 Chaouachi K. Hookah (shisha, narghile, “water pipe”) indoor air contamination in German unrealistic experiment. Serious methodological biases and ethical concern. Food Chem Toxicol 2010;48(3):992-5. Doi:10.1016/j.fct.2010.01.020
 ASH (Action on Smoking and Health). ““Shisha 200 times worse than a cigarette” say Middle East experts””. 27 March 2007 (prepared by Martin Dockrell)(accessed 13 June, 2008) [based, among others, on an interview with Wasim Maziak and Alan Shihadeh]
 Gay G. Hubble bubble babble. Health activists’ recent denunciations of water pipe smoking make cigarettes almost look healthy by comparison. Tobacco Reporter 2007 (June).
 Katurji M, Daher N, Sheheitli H, Saleh R, Shihadeh A. Direct measurement of toxicants inhaled by water pipe users in the natural environment using a real-time in situ sampling technique. Inhal Toxicol. 2010 Nov;22(13):1101-9. Doi:10.3109/08958378.2010.524265)
 Daher N, Saleh R, Jaroudi E, Sheheitli H, Badr T, Sepetdjian E, Al-Rashidi M, Saliba N, Shihadeh A. Comparison of carcinogen, carbon monoxide, and ultrafine particle emissions from narghile waterpipe and cigarette smoking: Sidestream smoke measurements and assessment of second-hand smoke emission factors. Atmospheric Environment 2010; 44(1): 8-14. Doi:10.1016/j.atmosenv.2009.10.004
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Conflict of interest
The author wishes to point out again that he has no competing interest: either in the pharmaceutical or tobacco industries, as previously stated in the FCT journal [
10]. If necessary, extensive details can been found in the corresponding section of other publications .
 Chaouachi K. Hookah (Shisha, Narghile) Smoking and Environmental Tobacco Smoke (ETS). A Critical Review of the Relevant Literature and the Public Health Consequences. Int. J. Environ. Res. Public Health 2009; 6(2):798-843.
 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.