Syria, with love (source: our book, 2007) 
Article published in 2013 in the British Journal of Cancer, shattering in only 1,000 words one full decade of pseudoscientific claims and methods regarding the so-called toxicity of the Middle East Peace Pipe (Hookah, Shisha, Narghile)
Chaouachi K. False positive result in study on hookah smoking and cancer in Kashmir: measuring risk of poor hygiene is not the same as measuring risk of inhaling water filtered tobacco smoke all over the world. Br J Cancer. 2013 Apr 2;108(6):1389-90. doi: 10.1038/bjc.2013.98. Epub 2013 Mar 7.
> Author’s copy available from Researchgate.
Note: Technical problems related to the “clicking” on the bibliographical reference numbers have been reported to us. We apologise for this situation and we will do our best to fix them as soon as possible.
Hookah and Addiction
Please refer to the related sections (“
Myth of Addiction“) in the SciTopics on theGlobal EpidemicandMystique of Hookahs. See also the relevant section of a recent Knol on this issue (here). The fact that all recent epidemiological studies show that up to 80 % of users of the hookah (under its modern form) are not dependent(*)is in agreement with a former socio-anthropological analysis:
“Le but n’est pas de fumer pour satisfaire une dépendance ou calmer une anxiété mais de prendre le temps pour parler, s’écouter et partager, à tour de rôle, en se tendant fraternellement, rituellement et symboliquement le tuyau d’aspiration. Toute la mise en scène ne serait que prétexte à l’émergence d’une « situation » au sens sociologique du terme (Erving Goffman) mais aussi ludique (Johan Huizinga), artistique et libertaire (Guy Debord). »“
(*) unless the interviewees…are urged to change their mind as this happened in a study cited by WHO TobReg expert Katharine Hammond. Among other errors, and further to interventions in that country, the knowledge of participants improved to the point that they suddenly “realised” that ““waterpipe”” smoking was more addictive than cigarette use (11% before the questions were asked; 32% after they were asked…).
However, antismoking journals such as “Nicotine and Tobacco Research”, desperately keep hammering that “” waterpipes are addictive, too “”…
Hookah and Aliens
It is said that Ummites , who landed on Earth in March 1950, were smokers. However no information is given about their possible use of hookahs.
Hookah and Anthropology (Social & Cultural)
For ten years now, the silence of anthropologists, particular medical anthropologists, around the whole world, has been amazing, not to say dumbfounding. Indeed, was there nobody to point out that a hookah is not a mere “water pipe” prototype in a chemistry laboratory ? Such a silence has amounted to accepting that the issue needed to be treated exclusively through the (antismoking) biomedical research looking glass (medicalisation of the hookah issue). The rest of the story is well known (excerpt from our other Knol ). More information in a study on material culture, orientalism and neo-orientalism, in the practical (hookah lounges) and politics-of-science sense  .
See also the relevant
“Hookah and Time Passing”item.Hookah and Arab Uprisings Odissey of the 21st Century Dawn…
A friend of us wondered whether
“smoking bans have been a significant contributory factor to the unrest in the [Arab] region”. “Might they even have been major contributors?”, he asked. Part of the response can be found in the following online pieces:
Tunisian Jasmine-Red Revolution (Rouge Jasmin, by Le Journal de Personne)
The Syrian Ban on Smoking in Hospitality Venues (Cafes, etc.)The Lebanese Ban on Smoking in Hospitality Venues (Cafes, etc.)Prohibition Through the Hookah Looking-Glass (Speech)
The ambiance of water-pipe cafés” is not as new phenomenon. Westerners who, in the past centuries, visited or lived in the Middle East region -such as Pierre Loti (Turkey) or Alphonse De Lamartine (Syria and Lebanon), not to mention many orientalist painters-, had actually been enthralled by such an exotic and colourful atmosphere. Their writings or paintings show that they understood, from an anthropological viewpoint, that the very reason of such a special ambiance was the narghile itself  . In the modern era, a prestigious Lebanese lung specialist warned recently, from the very Middle East wherefrom the world narghile epidemic started two decades ago, that such a habit has been, for centuries, an actual “art de vivre”, i.e. an art of living well  . See also the relevant
“Hookah and Poetry”and“Hookah and Time Passing”items.
Hookah and Breath
A team led by a prestigious independent Syrian lung specialist has been able to shed new light on the respiratory effects of heavy narghile use among daily female users of tumbak (pure moistened tobacco, no molasses, no flavours, no glycerol). This was made possible thanks to their clear selection of exclusive/ever users. The researchers reported a higher proportion of chronic bronchitis in daily narghile heavy smokers and quasi-permanent alteration of maximum Maximal Mid-Expiratory Flow (MMEF 25%–75%) in narghile smokers when compared with cigarette smokers. Nonetheless, alteration of FEV1 was more important in cigarette smokers  . Another team led by a pnot less prestigious independent Tunisian physiologist has found that daily heavy narghile use of plain unflavoured tobacco-molasses mixture of the jurak type accelerates the ageing of the lung  .
Hookah and Cafes
In a seminal article published in
Addiction(an anti non-Farmingtonian “peer-reviewed” antismoking journal), the world famous ““waterpipe”” epidemiologist Wasim Maziak put forward a so-called ““cafe culture”” as another reason for the world “epidemic”… However, it is well known that the first cafes in the world were already functioning in the Middle East far back by the 16th century and their early adopted distinguishing feature was the narghile.
See also the
“Hookah and Art de vivre”,“Hookah and Society”and“Hookah and Time Passing”items.
Hookah and Cancer
Further to a long series of health scares, an international team has eventually led the first aetiological studies on hookah smoking and cancer  . The researchers measured CEA (Carcino-Embryonic Antigen) levels in rigorously selected exclusive hookah smokers (in remote villages of the Punjabi countryside) who have been using, for decades and in several daily sessions, large amounts of tobacco (the weight equivalent of up to 60 cigarettes in the bowl). They did not have any preconceived idea of their results before setting about the study. They just “tested to see what would happen”, as a critique of recent reviews on cancer stressed  . They focussed on the most important confounding factor (non-exclusive hookah smoking) since a previous study of theirs showed that mixed hookah/cigarette smokers had mean CEA levels different from those of cigarette smokers. Globally taken and bearing in mind the last detail about the quantity of tobacco, the mean levels (though varying between so-called “light” smokers and “heavy” smokers) appeared to be much lower than those reported among cigarette smokers. Note: Serious errors repeatedly published in the so-called peer-reviewed “”waterpipe”" literature  are frequent (and obviously meant) when it comes to cancer . See, for instance, the case of bladder cancer . More details are provided in the Diseases section of the
Biomedical & Anthropological Perpective KnolSee related aKnol about a “systematic review”(on cancer studies in particular) by Elie Akl et al. (University of New York at Buffalo),published in the International Journal of Epidemiology.
PS: see also the relevant
“Hookah and Tea Drinking”item.
Hookah, Cannabis and Opium
The use of cannabis use in a water pipe (Chine”bang”, modern “bong”, etc.) is not a new phenomenon. However, a dramatic increase in the frequency of this drug use mode has been recently witnessed  . An anthropological transdisciplinary outlook on the use of cannabis in a water pipe supports the neuro-pharmacological aspects developed in a recent study.An entire book was early dedicated to these hot issues  . An updated summary was published in a pharmaceutical journal  . Through history, opium has been used in hookah (alone or mixed with tobacco) and still it is in some areas of Asia  .
However, 95% of users of the modern hookah (shisha) smoke moassel/tobamel, a flavoured mixture of tobacco and molasses/honey.
Hookah and Children
The WHO (World Health Organisation) flawed report says it is common [“not uncommon” (sic)] to see children smoking the hookah (narghile) with their parents in the Arab world. This is a gross scientific error. Sources establishing the opposite have been brought out in a critique of this UN document  .
Hookah and Cigarettes
All comparisons are generally anti-scientific and sometimes insane  .See a relevant Knol criticising a recent study (CO, COHb, plasma nicotine) or a critique of a BBC report (exhaled CO):
“In the ideal world of public health, overstating the dangers of shisha will persuade its users to cease using tobacco products. In the real world, claims that shisha can be up to 450 “more dangerous” than cigarettes ismore likely to encourage users to switch to cigarettes. It is the kind of unintended (but hardly unforeseen) consequence that has dogged the anti-smoking movement efforts for decades.” 
Hookah and CO (Carbon Monoxide)
This issue has triggered countless scares around the world. See a short recapitulation in the relevant section of a recent Knol on this issue.See a relevant Knol criticising a recent study on this issue or a critique of a BBC report (about a study on exhaled CO)  .
Hookah and Drugs
“Hookah, Cannabis and Opium”item.Hookah and E-Cigarettes (and E-Hookah)
We would like to refer to an online comment on an article published in the British Medical Journal in which the authors warn against the possible “hidden” hazards of E-cigarettes… We discuss the similarities between E-cigarettes and hookahs (with the moassel mixture) and we speculate on the usefulness of a E-hookah in the light ofprehistoric harm reduction techniques…  . For information, a
SciTopicaddresses the question: “Is the Electronic “Healthy Shisha” Really Healthy ?”.Hookah and Ethics (Double Standard)
This relates to the scientific misconduct of antismoking researchers whosegreat majorityisaffiliated with Globalink , the world antismoking network of about 6,000 researchers/organisations around the world, sponsored by the pharmaceutical industry (Pfizer laboratories among others). The non-exhaustive list of ethical problems is as follows:
-Absolutely (sorry to be so strongworded) pure junk science (e.g. “Tobacco Smoking using a Waterpipe: a re-emerging strain in a Gobal Epidemic”) publishedb y Maziak et al. in the antismoking “Tobacco Control” journal and cited over and over again by parroting crowds of researchers  ;
-Laundering and recycling erroneous pseudo-scientific reports (Maziak et al., Cochrane)  ;Abusing of “meta-analysis” and ending up comparing oranges with apples(Neergaard et al., Nicotine and Tobacco Research)  . See tentative related Knol on Anthology of errors .
Lies; Fallacies; Photomontages(WHO, INPES, American Lung Association);
-Methodological/magical tricks with a “magical” “standardised” smoking machine  .
- Plagiarism in tobacco research (by top national antismoking authorities…);
Meta-plagiarism. See:Du plagiat au métaplagiat ou les métastases d’un totalitarisme en germe
-Deceiving the public on the real objectives of antismoking campaigns. As an example, the logo of the US-funded SCTS ( “Syrian Centre for Tobacco Studies”; Wasim Maziak, Thomas Eissenberg, Kenneth Ward), the main world““waterpipe””antismoking centre, represents a narghile (““waterpipe””), not a cigarette…
-Censorship (stifling dissent view); religious consensuses such as the Farmington one  (cf. antismoking journals: “Tobacco Control” journal, “Nicotine and Tobacco Research”, “Addition” journal, etc.); Publication bias; Xenophobic bias. For examples, see related Knol about a “systematic review” published in the International Journal of Epidemiology and the below entry titled
“Hookah, Pseudo-Science and Xenophobia”;
-Religious antismoking ideology sold as “good” “peer-reviewed” “science” to the media; Puppeteering the latter so that their interviews always involve the same experts or those affiliated with the same organisations ( Globalink ), never with independent scientists.
-Hazardous use of
human guinea pigsin some studies.
-Manipulation of governmental decisions and populations (smoking bans in the name of “public health”) through the widely advertised publications of twisted statistics  ,“studies”  and WHO reports full of errors, strikingly biased WHO “expert” recommendations  , etc.
-Nepotismand undeclared conflicts of interests (see related Knol on theLebanese Ban on Smoking). “Peer-review” masquerade as most of the time, “peer-reviewers” of tobacco smoking related articles are affiliated (without declaring this as a blatant competing interest) withGlobalink, the world antismoking network of about 6,000 researchers/organisations around the world, sponsored by the pharmaceutical industry (Pfizer laboratories among others);
-Systematic abuse of public money ($ millions) when, in poor countries, millions are dying of food deprivation (and others, in wealth countries, of food pollution…);
funding by the Tobacco Industry (cigarettes): see the“Hookah and the Tobacco Industry”item.
Open xenophobiain the British Medical Journal:see Knol onHookah Smoking Prophet
Censorship (silencing the whistle blower). The examples are countless. Among the most recent ones, see post-hoc censorship (named “retro-censure” in French) in theHarm Reductionjournal after the Jordanian antismoking authors (Najla Dar-Odeh et al) of a criticised article wrote (instead of addressing the numerous scientific errors in their papers) to the Editor-in-Chief (Dr Drucker) to demand the retrieval of our critique (peer-reviewed by twice by the Editors) that has been online for 3 months… SeeKnol:Jordanian Study on Narghile (Hookah, Shisha) Tobacco Smoking
-A huge scientific and ethical fraud involving a strange “peer-reviewer” for the
Inhalation Toxicologyjournal and a not less amazing editor-in-chief (Donald Gardner). Seeonline document
Time has come that all these ethical violations be put on a trial by an independent international court of justice ( The Hague speech ).
Hookah and ETS (Environmental Tobacco Smoke)
A hookah produces almost no side-stream smoke. Inappropriate use of charcoal tablets (sometimes meant by antismoking researchers) has created some confusion. Over the past years, and in agreement with a world prohibition agenda, national “experts” have frequently resorted to anti-scientific statements and even fake posters and images (showing, for instance, a “big plume” of smoke stemming from the bowl of a hookah.). An online open access 50 page study has clarified the issues at stake  . See also the relevant section of a recent Knol on this issue and one entitled “
Waterpipegate and Climategate“.See also a Knol about theMade-in-the-USA Lebanese Smoking Ban.
Hookah and Scientific Fallacies
Doctors (Andrew Chan and Susan Murin, USA ) contend that the “Harmless Hookah” is just a fallacy … Is the problem well posed (“harmless” or “harm-reducing”)? This is another story… We have noted that their judgment relies on “systematic reviews” published by a team of US researchers whose leader, Elie Akl, has even been interviewed in the form of a ” podcast “. By sense of modesty and reserve, we will not mention the existence of a strong critique of the above materials…
Hookah as a Gateway (to Cigarette Smoking)
This is a new scare on behalf of antismoking researchers. The truth is that the cited studies (particularly those by Virginia Rice and her team at Wayne University (Michigan)) are highly biased. See the relevant section of a recent Knol on this issue
.Hookah and Harm Reduction
Hookah, as the pre-Columbian tobacco harm reduction technique, had not posed any particular public health problem for centuries  . It began to pose a “probem” (health?, social?, cultural?, political?, economical?) since 2002, the inception date of the “”waterpipe” antismoking US-funded SCTS “Syrian Centre for Tobacco Studies”… The question
“Why only after year 2002?”has been addressed in previous peer-reviewed publications (e.g.here) and in aSciTopic. However, smoking patterns have changed a lot and smoking too often occurs in ill-ventilated places where, not less frequently, a new kind of charcoal (quick-lighting and non natural) is used as a heating source. Possibilities to reduce the emissions of such a gas within a broad harm reduction framework should have become a public health priority for ten years now. Although no serious individual or group said hookah was “harmless”, the global antismoking activists have stuck to this notion in order to justify their permanent war. The latter is based on the same “game” as oil geopolitics which destroyed entire countries and killed millions of individuals (Afghanistan, Iraq, Libya, etc.): seeWilliam Engdahl).
Dr JK Anand:
“Instead of seeking religious approval for anti-smoking efforts, an attempt should be made to reduce harm”.
See also recent approaches by Shishavac and Sultana-Med . But there are many others.
Hookah and Health
This is too big a topic for a FAQ theme. Please refer to the “Hookah and Breathe”, “Hookah and Tuberculosis”, etc, items. See also the highly relevant SciTopic on Global Epidemic .
Hookah and History (its Origins)
It is not India but Eastern Africa (Ethiopia, year 1320) as early established  . This fact was hihglighted in the critique of the WHO flawed report in which the ““waterpipe”” experts insisted on an Indian origin  For the reasons of such a suspect focus on India, see the
relevant sectionof a recent knoll entitled “Origins of the hookah and the “modern” antismoking “concept” of “denialism””. We also have Shirazi’s poem (heralding theKnol on Irani women), the first one in history about tobacco smoking (1535). Interestingly, it is a poem of love.
According to a more recent hypothesis put forward by the narghile culture revolutionary
Shishavac Group, in days of yore, an Arabian Newton was sitting under a coconut tree when a fruit fell on his head…. It is said that he suddenly thought of the Universal Law of Smoke Water Filtration…Hookah and Love
« Fî qahwé ‘a-l-mafraq ; Fî mawqidé u fî nâr ; Nebqâ ’enê w-hebîby ; Nefreshhâ b-’el-’asrâr… »
[There is a coffee-house there by the crossroad, with a brazier and some fire. I used to stay there with my love, carpetting its walls with secrets]. Lebanese singer Feyrouz (cited in doct. thesis on narghile, footnote 511). See also ” Hookah, Peace and Love ” Knol.
See the “Hookah and Peace” item.
Hookah and “Nicotine Addiction”
See the “Hookah and Addiction” item. Please refer to the related sections (“Myth of Addiction”) in the SciTopics on the Global Epidemic and Mystique of Hookahs . Please aslo consider the relevant section of a recent Knol on this issue ( here ).
Hookah and Peace
See the”Hookah and Art de Vivre”, “Hookah and Poetry” and “Hookah and Time Passing” items. See also
Peace Pipe speechdelivered in The Hague (15 March 2010) to bring back social peace and peace between nations. See also “Hookah, Peace and Love” Knol.Hookah and the Pharmaceutical Industry
See the “
Hookah and Research (and its Funding)” item and also the ” Hookah and the Tobacco Industry
Hookah and Poetry
See the heralding poem of the Knol on Irani women . It is the first poem in the world on tobacco smoking (hookah, qalyan) and it is a poem of love. Shirazi (1535) is its author. The related context was studied in detail in two books  . See also the relevant
“Hookah and Art de Vivre”item. See also “Hookah, Peace and Love” Knol.Hookah and Politics
Quotation from Bertrand Dautzenberg, president OFT, top national French antismoking authority, and Jean-Yves Nau (medical journalist with Le Monde daily newspaper), authors of a 144 page “book” (actually: plagiarised material and the greatest scientific fraud in the history of tobacco research)  on the great hazards posed by hookah smoking, and particularly passive smoking:
“We are heading towards a political conflict when hookah lounges close by the 1st of January 2008” [original in French: «D’ores et déjà, un risque de conflit politique se profile avec l’arrêt de l’activité des bars à chicha au 1er janvier 2008»)(page 72).
This “book” aimed to be the “scientific basis” for the French Ministry of Health. On a political level, the hookah lounges resisted thanks to the set up of a national profession union. On a scientific level, the corresponding shoddy science was debunked. Add to this the ethical aspects of blatant plagiarism and the hookah lounges stayed open in spite of the decree.
See also the relevant
"Hookah and Time Passing"item.Hookah and the Prohibition Agenda
interviewwith the author run by investigative journalist and researcher Chris Snowdon.
-See speech delivered at the
TICAP conference(The Hague/The Netherlands, 15 March 2010).
-Browse the site of the FCTC (Framework Convention for Tobacco Control) mentioned in the introduction. Read also see elsewhere cogent critique of FCTC .
-See the quality of the "studies" on which the United Kingdom smoking ban relies  .
-See also the relevant
“Hookah and Religion”item.
-Consider the recent call by a researcher from the University of Virginia who, after drawing a review of pseudo-science, is warning local “public health” officials that “exemptions for hookah bars in clean indoor air legislation” is a “public health concern”  .
Hookah, Pseudo-Science and Xenophobia
Instrumentalising any new fear in relation to a well known geopolitical agenda is no news. The substantial pseudo-science on “”waterpipe”" that is pouring since year 2002 has undoubtedly fuelled xenophobia(as if the wars that cost millions of lives since 2003 were not enough) including xenophobic bias in some studies. See Knol titled
The British Medical Journal’s Hookah Smoking Prophet. See alsorelevant sectionof recent Knol on this issue.
> USA:“The owner of a hookah lounge in Worth believes some residents of the neighborhood near his cafe do not want him there because he is of Middle Eastern descent”.
> Denmark(the country of the famous «caricatures»…): “I would say that we will have a ban before the arrival of spring […]” said the Head of the Parliamentary Health Committee, Preben Rudiengaard (Venstre). “Rudiengaard has support from a parliamentary majority. Both Dansk Folkeparti, Socialdemokratiet, SF, and Enhedslisten support a ban […]”.
> Switzerland(the country where minarets are forbidden… ): “As for ETS “social aspects”, the WHO experts were wrong when stating that it is common (“not uncommon”) for children in the Arab world to smoke narghile with their parents. Here, DIETHELM appeared to be “more Catholic than the Pope” and stressed that numerous parents (in Switzerland, apparently immigrants and likely from the same region) allowtheir children, sometimes aged less than 12 years, to gather at home and smoke hookah in group (Original: « […] de nombreux parents, […] parfois de très jeunes adolescents de 12 ans ou moins […] dans le logement familial […]”). It appeared that the authors of the WHO report had no data to support what they apparently put down in a hurry. For this reason, DIETHELM is kindly requested to inform on the scientific sources supporting his harder (than WHO’s) facts.” Source: A critique of Pascal DiethelmHookah and Radioactivity
The hazards of cigarette radioactivity have been hyped according to some researchers. Concerning hookah, the main reference in this field is a recent pioneering study which showed no substantial difference between cigarette and hookah tobacco  .
Hookah and Religion
Dr JK Anand:
“Instead of seeking religious approval for anti-smoking efforts, an attempt should be made to reduce harm”.Hookah smoking is neither “haram” (illicit, the equivalent of Jewish “treif”) nor “halal” (licit, the equivalent of Jewish “kosher”).ts use was not reported by the times of the Revelation. However scholars, by contrast with present antismoking researchers, have been tolerant over centuries. Now under the pressure of US “public health” agencies, some of them are changing their views. Indeed, prohibition is antithetic to religion as a holy verse states : « Lâ ′ikrâha fî-d-dîn » (Let There Be No Compulsion in Religion) (Qur’ân: II, 255).The believer is asked to follow the Prophet’s precept:Seek science from the cradle to the grave:Examples of this science, which is, of course, good, quality science, can be found, among others, in:Glimpses of Islamic Civilisation;Roshdi Rashed’s encyclopaedic works ;Philippe Büttgen et al’s debunking of denialists’claims. Consequentely, a critical mind is the first quality of the sincere believer. In a world polluted by numerous health scare frauds (environmental tobacco smoke, to start with), the believer should be very cautious, particularly when prohibition measures rely on fraudulent statements issued by “experts” (from the World Health Organisation in particular) and disseminated through the mass media: e.g.:Hazardous Vaccination;Swine Flu” “Pandemic”;“Shisha & Swine Flu” Scare. In sum,what is above all “haram” (illicit, i.e.not “kosher”)in religion is pseudo-science, even more when the latter serves personal interests or those of wealthy pharmaceutical companies.
When prohibition of smoking in public parks (as in the United Arab Emirates) relies on such pseudo-science (actually imported from California), then it is also “haram” (illicit, i.e. not “kosher”). Recently, a friend informed us that a suspect site supposedly “debating” these very issues (shisha smoking as “haram”/”Treif” or “Halal”/”Kosher”?) has rejected her comments because she actually referred to our analysis…
When an international convention -such as the
FCTC(Framework Convention for Tobacco Control)- relies on shoddy science, then it is “haram” and wisely-led States should withdraw from it in order to conform with their religion. More details on a proposed scenario can be found in a speech delivered at theTICAP conference(The Hague/The Netherlands, 15 March 2010).
Finally, the case of moassel (meaning “honeyed” in Arabic), the tobacco-molasses/honey smoking mixture, needs some clarification in the light of this discussion. There is a holy verse highlighting the holy (therefore, “halal” (licit)) nature of honey :
“And thy Lord taught the Bee to build its cells in hills, on trees, and in (men’s) habitations. Then to eat of all the produce (of the Earth), and follow the ways of thy Lord made smooth. There issues from within their bodies a drink of varying colors, wherein is healing for men. Verily in this is a Sign for those who give thought.”(Qur’ân, XVI, 68-69). This is another explation for the universal acceptance and popularity of this product. All these issues, including that of religious egalitarianism regarding hookah use (by Christians, Muslims, Jews, Buddhists, Hinduists, etc.) has been studied in detail in an early transdisciplinary comprehensive doctoral thesis.
More on religionand hookah smoking: see SciTopic titled The Mystique of Hookahs . See also “
Love as Religion” Knol.Hookah and Research (and its Funding)
See interview with the author run by investigative journalist and researcher Chris Snowdon. Since 2002, the research led by the “”waterpipe” antismoking US-funded SCTS “Syrian Centre for Tobacco Studies” ( Wasim Maziak [interview], Thomas Eissenberg, Kenneth Ward) and their colleagues at the US-American University of Beirut ( Alan Shihadeh )[interview], has focused almost exclusively on “”waterpipe”" smoking, not on cigarettes (whose prevalence in countries like Lebanon or Syria is however much more important). These centres are funded (US Fogarty International Centre, US National Institute of Cancer) to up to $10 million. The direct or indirect role of the pharmaceutical industry (nicotine patches, gums, Chantix, etc.) will be clarified in a future study. With dozens of “”waterpipe”" studies, the quantity is certainly there. However, the quality is very poor and the resulting confusion has been tragic against the background of a world epidemic  . .
See the relevant
” Hookah and the Tobacco Industry ” item.Hookah and Respiratory Problems
See the relevant
“Hookah and Breath”item. Please note that heavy use leads to lung ageing. Hookah and Smoking Machines
The fraud (of modelling hookah smoking thanks to a biased smoking machine [US-American University of Beirut]) has been criticised in a detailed peer-reviewed study  . See also the relevant section of a recent Knol on this issue.
Hookah and Tar
Hookah tar and cigarette tar are completely different from each other (taboo talk). The question of temperatures is of utmost importance because of its tremendous consequences  . This important fact was not acknowledged in the WHO (World Health Organisation) flawed report in which the “”waterpipe”" experts “gave to understand” to the world that cigarette and hookah could be compared on this basis  . Such an attitude is unethical and anti-scientific. See also the relevant section of a recent Knol on this issue. The confusion is huge. US-American University of Beirut “”waterrpipe”" antismoking researchers even believe (this was published in a respectable peer-reviewed scientific journal…) that tar can be found in the tobacco leaves (cigarettes) or the very moassel (tobacco-molasses smoking mixture)  . However, tobacco researchers worthy of this name know that
tar only appears when tobacco is burnt….
Hookah and Tea Drinking
Hot tea drinking may lead to oesophageal cancer  . This may have implications for hookah smoking… 
Hookah and Time Passing
A full chapter of our first book (1997) was dedicated to this important issue that encompasses psychological, philosophical and poetic aspects  . Hookah is known to be a catalyst of conversation by sparking up poetic, love and intellectual discussions. Indeed, it often is a mere excuse or pretext for conversation as with the antemeridian rosé glass in Pierre Sansot’ novel :
«Ainsi, en cette matinée lumineuse d’avril, il s’est assis seul, à la terrasse d’un café, face à un verre de rosé auquel il n’a pas encore touché. Il paraît heureux. Est-ce seulement l’effet d’un ciel serein, d’une rue accueillante et qu’aucune foule ne tourmente ? A tel point que le verre de rosé constituerait à peine un alibi » .
The second book (2002, new ed: 2007) on hookahs also mentions the case of Yemen and an interesting scene in a novel by Honoré de Balzac  .
From a political anthropology perspective, Paul Lafargue (Karl Marx’ son-in-law)’s highly relevant book -titled “
Le droit à la paresse [The Right to Be Lazy]- was extensively commented.Hookah has indeed a communistic libertarian dimension because the alternative values it suggests are play, conversation and idleness. From there, and particularly outside Asia an Europe, hookah actually gets individuals away from television, its propaganda and commercials. It can be therefore seen as a serious threat to the New World Order. Indeed, through history, authoritarian governments used to send police eavesdroppers to narghile cafes. These times may come back again…
Hookah and the Tobacco Industry
The Tobacco Industry (TI) has kept amazingly silent while watching the hookah scene. By contrast with the Pharmaceutical Industry, its researchers have not published a single study on hookah although they would be much more qualified. In fact, hookah is an economic rival for the TI even tougher that it has not been designed in any modern laboratory but rather takes its roots in centuries-old traditions. Furthermore, unlike cigarettes, its addictive potential (in its modern form) is so small. Int he best case, hookah could have represent a “call” product for cigarettes. Unfortunately, once again, studies show that the “Gateway” (switching from hookah to cigarette use) hypothesis is not warranted  … See the most relevant Knol titled:
Big Tobacco & Big Pharma Against “Oriental” Hookah Outsider
This article contains embarassing evidence (blatant non-disclosure of striking conflicts of interests) for the Pharmaceutical Industry, the Tobacco Industry and the authors (World Health Organisation official “”waterpipe”" experts) of the mainstream anti-”"waterpipe”" smoking studies since year 2002. Furthermore, the Editors of the following journals (in which these ethical breaches took place) have not published (after they have been informed) any apology for the open conflicts of interest: the
Food and Chemical Toxicologyjournal; theAtmospheric Environmentjournal; theInhalation Toxicologyjournal.
To make it even smarter, the latter included another huge scientific and ethical fraud on behalf of its Editor-in-chief (Donald Gardner) and a so-called “peer-reviewer”. Details can be found in an online document . To top it all, the “
Elsevier” and “Informa Healthcare” publishing groups, owners of the above journals and boasting of sticking to a rigourous “code of conduct” and high ethical standards, have adopted the same strategy: sweeping the scandal under the carpet… In these repeated conditions, one may rightly conclude that when it comes to the “Oriental” way of smoking, everything is permitted. There is actually a double ethical standard: one for the “West” and another one for the Middle East. See the “Hookah, Pseudo-Science and Xenophobia” item.
See also the relevant
“Hookah as a Gateway”item, the ” Hookah and Research (and its Funding) ” item and the“Hookah and the Pharmaceutical Industry”item. Please also refer to the related sections (“Myth of Addiction”) in the SciTopics on theGlobal EpidemicandMystique of Hookahs. See also the relevant section of a recent Knol on this issue (here).
Hookah and Teeth
Hookah and Tuberculosis (communicable diseases)
Fortunately, this tobacco habit has not raised any major health problem for centuries. However, because of changes in its use, it can pose new problems that have not been soundly analysed so far. For instance, one cannot squarely state that narghile is an “unexpected means of transmission of infections. Narghile, and water pipe in general, was early identified as a means of potential transmission of pathogenic germs, tuberculosis in particular, because of the social habit of passing around the suction hose from mouth to mouth. Fortunately, individual aseptic nozzles have been commonly used and on a large scale in cafes and restaurants around the world. However, errors and misrepresentations are unfortunately very frequent about communicable diseases. In a paper published in The Lancet Infections, a researcher who relied exclusively on the WHO flawed report on ““waterpipe”” smoking , replicated the errors found therein about tuberculosis  .
Hookah and “”Waterpipe”
The ““waterpipe”” neologism (in one word) was officially endorsed in 2004 according to a functionalist definition : ““waterpipe”” are “tobacco use methods in which smoke passes through water”  . This term proved to be a scientific nominalism as, for almost one decade, virtually all researchers in this field have considered that ““waterpipes”” are more or less a same material object across space and time  .
“Using ““waterpipe” -instead of the natural words (three main ones: hookah, shisha, narghile) used by peoples in their daily language and to be found in all dictionaries of the world- has implied the blind endorsement of a scientific nominalism with tremendous consequences on research. By using an imposed neologism outside a given and limited geographical area, their users just draw a parallel between devices known to produce fumes with very different chemical compositions and corresponding smoking patterns. For instance, a shisha (in which the charcoal and smoking mixture are separated by a tin foil and in which temperatures scarcely go in excess of 150°C) used in New Zealand is completely different from a Chinese water pipe (involving a tiny amount of tobacco and no charcoal) or an Egyptian goza (direct contact between the charcoal and the mixture in which temperatures are higher)”  .
“Practically, the following statement “The Chinese water pipe [in 2 words] is smaller than the Iranian narghile” is true from a logics viewpoint. “Iran has two main water pipes: Narghile and Qalyan”and ““Mada‘a” is the national Yemeni water pipe even though there are other types”are also true statements. However, statements as “”Waterpipe” is [this or that]” or“”Waterpipe” use causes [this or that] disease], without any given information about the geometry of the pipe, the nature of the smoking preparation (tobacco, no tobacco, molasses or not, charcoal or not, etc.) are false from the same scientific viewpoint”  .
Hookah and Women (incl. pregnant women)
Contrary to prevalent neo-orientalist views on behalf of biomedical researchers, having studied abroad (in Europe and the USA in particular), women have been smoking narghile for centuries  , particularly in a country like Iran (image: left). The WHO (World Health Organisation) flawed report contained serious errors in this respect. See critique of this expert document  .
The World Health Organisation (WHO) is bound by the mandate of working for protecting and improving the public health of all peoples. However, it 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. Instead, the only objective of the highly paid WHO experts has been hookah use eradication in parallel with the promotion of expensive though inefficient pharmaceutical methods and products (nicotine patches, gums, Chantix/Champix, etc.).
In these conditions, and pending accountability to be put on trial in an international court  we, once again, take the historic responsibility of advising pregnant women to avoid smokingduring the corresponding period. We even invite them to try theNarguilox(Oxygen Bar) in which, may we note, we have unfortunately no competing interests.
(*) leaving aside the negative results of a recent study which found no deleterious effect of narghile smoking on Intra-Cytoplasmic Sperm Injection outcome.
Note to the reader: if you have understood what is globally at stake, then you will not be surprised to see that most of the cited references below come from one sole author. If you find similar critical views aired elsewhere (in scientific publications) by other individuals, and in relation to this very topic, then please feel free to tip :kamcha*gmail.com
REFERENCES [further to failed migration from the Knol articles]
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3. Mohammad Y, Kakah M, Mohammad Y. Chronic respiratory effect of narguileh smoking compared with cigarette smoking in women from the East Mediterranean region. Int J Chron Obstruct Pulmon Dis. 2008;3(3):405-14.
4. Chaouachi K. Narghile (hookah, shisha) tobacco smoking: expect the unexpected everywhere and not only in Syria. Int J Infect Dis. 2009 Dec 15. [Epub ahead of print]. doi:10.1016/j.ijid.2009.08.016 http://dx.doi.org/10.1016/j.ijid.2009.08.016 <http://dx.doi.org/10.1016/j.ijid.2009.08.016>
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9. Maziak W. The waterpipe: time for action. Addiction. 2008;103(11):1763-7.
10. Chaouachi K. Le narguilé. Anthropologie d’un mode d’usage de drogues douces [Anthropology of Narghile: its Use and Soft Drugs], Paris, 1997, L’Harmattan, 262 pages. http://www.harmattan.fr/index.asp?navig=catalogue&obj=livre&no=10880 <http://www.harmattan.fr/index.asp?navig=catalogue&obj=livre&no=10880>
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12. 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 http://dx.doi.org/10.1016/j.mehy.2009.11.036 <http://dx.doi.org/10.1016/j.mehy.2009.11.036>
13. 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 http://www.em-consulte.com/article/231124 <http://www.em-consulte.com/article/231124>
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15. Chaouachi K. To whom does ‘public health’ belong when it comes to ‘Waterpipe’ Smoking ? Australian and New Zealand Journal of Public Health 2008; 32 (6): 583. doi: 10.1111/j.1753-6405.2008.00319.x http://www3.interscience.wiley.com/journal/121559909/abstract <http://www3.interscience.wiley.com/journal/121559909/abstract>
16. Chaouachi K. Hookah, opium and tobacco smoking in relation to oesophageal squamous cell carcinoma. Br J Cancer. 2009 Mar 24;100(6):1015. http://www.nature.com/bjc/journal/vaop/ncurrent/abs/6604958a.html <http://www.nature.com/bjc/journal/vaop/ncurrent/abs/6604958a.html>
17. Chaouachi K. A Critique of the WHO’s TobReg “Advisory Note” entitled: “Waterpipe Tobacco Smoking: Health Effects, Research Needs and Recommended Actions by Regulators. Journal of Negative Results in Biomedicine 2006 (17 Nov); 5:17. doi:10.1186/1477-5751-5-17 http://www.jnrbm.com/content/5/1/17 <http://www.jnrbm.com/content/5/1/17>
18. Chaouachi K. Harm Reduction Techniques for Hookah (shisha, narghile, “water pipe”) Smoking of Tobacco Based Products. Med Hypotheses 2009 Oct;73(4):623-4. http://dx.doi.org/10.1016/j.mehy.2009.06.016 <http://dx.doi.org/10.1016/j.mehy.2009.06.016>
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20. Chaouachi K. [E-Letter to the Editor] E-Cigarettes, Hookah (Shisha, Narghile) and E-Hookah. British Medical Journal 2010 (29 Jan). http://www.bmj.com/cgi/eletters/340/jan19_1/c311#230446 <http://www.bmj.com/cgi/eletters/340/jan19_1/c311#230446>
21. Chaouachi K. Hookah (Shisha, Narghile) Smoking and Environmental Tobacco Smoke (ETS). A Critical Review of the Relevant Literature and the Public Health Consequences. International Journal of Environmental Research and Public Health. 2009; 6(2):798-843. http://www.pubmedcentral.nih.gov/articlerender.fcgi?tool=pubmed&pubmedid=19440416 <http://www.pubmedcentral.nih.gov/articlerender.fcgi?tool=pubmed&pubmedid=19440416>
22. Anand JK. [E-Letter to the Editor] Irrelevancy of religion in smoking. British Medical Journal 2003 (11 May). http://www.bmj.com/cgi/eletters/326/7396/962#32155 <http://www.bmj.com/cgi/eletters/326/7396/962#32155>
23. Chaouachi K: Le narguilé : analyse socio-anthropologique. Culture, convivialité, histoire et tabacologie d’un mode d’usage populaire du tabac [Narghile (hookah, shisha): a Socio-Anthropological Analysis. Culture, Conviviality, History and Tobaccology of a Popular Tobacco Use Mode]. Transdisciplinary doctoral thesis, Université Paris X (France). 420 pages, 850 footnotes, detailed bibliography, illustr.
24. Van Der Merwe NJ: Cannabis Smoking in 13th-14th Century Ethiopia: Chemical Evidence. In World Anthropology: Cannabis and Culture. Edited by Vera Rubin: Mouton Publ. (The Hague); 1975: 77-80.
25. Chaouachi K. An Open Letter against plagiarism and plagiarists. Tabaccologia 2009; 1: 46-7 [English version] http://www.harmattan.fr/index.asp?navig=catalogue&obj=article&no=10155 <http://www.harmattan.fr/index.asp?navig=catalogue&obj=article&no=10155>
26. Chaouachi K. UK Ban on Smoking in General and on Hookah Smoking in Particular Should Not Stay. British Medical Journal2009 (18 Mar) http://bmj.com/cgi/eletters/335/7609/20#210647 <http://bmj.com/cgi/eletters/335/7609/20#210647>
27. 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 http://dx.doi.org/10.1016/j.fct.2010.01.020 <http://dx.doi.org/10.1016/j.fct.2010.01.020>
28. Matthew Piechalak. Worth, hookah lounge agree to reduced hours. The Reporter, Sep 03, 2009. http://www.thereporteronline.net/atf.php?sid=17234¤t_edition=2009-09-03 <http://www.thereporteronline.net/atf.php?sid=17234¤t_edition=2009-09-03> 29. Voltaire (Opinion-editorials deciphered). Caricatures and hysteria that disguise the truth. Voltaire 2006 (2 March) http://www.voltairenet.org/article136203.html <http://www.voltairenet.org/article136203.html>
31. Jacon Gyldenlove (Translation Martin Lamberth). Ban on hookah tobacco in the works. Dr.dk 09 Nov 2009. http://www.dr.dk/Nyheder/Andre_sprog/English/2009/11/09/092616.htm <http://www.dr.dk/Nyheder/Andre_sprog/English/2009/11/09/092616.htm>
32. Chaouachi K. E-Letter: Denialism, Hookah Environmental Tobacco Smoke, and the «Overwhelming Consensus on the Evidence». Eur J Public Health. 2009 (17 Feb). >> A critique of : Diethelm, P, McKee, M. Denialism: what is it and how should scientists respond? Eur J Public Health. 2009; 19:2-4. http://eurpub.oxfordjournals.org/cgi/eletters/19/1/2#114 <http://eurpub.oxfordjournals.org/cgi/eletters/19/1/2#114>
33. Diethelm P. Narguilé : attention, danger ! Dossier 07-003 – 2007-05-29. OxyGenève 2007 (May). Accessed 31 Jan 2009 http://www.oxygeneve.ch/dossier.php?id=67 <http://www.oxygeneve.ch/dossier.php?id=67>
34. Khater AE, Abd El-Aziz NS, Al-Sewaidan HA, Chaouachi K. Radiological hazards of Narghile (hookah, shisha, goza) smoking: activity concentrations and dose assessment. J Environ Radioact. 2008 Dec;99(12):1808-14. http://dx.doi.org/10.1016/j.jenvrad.2008.07.005 <http://dx.doi.org/10.1016/j.jenvrad.2008.07.005>
35. Pulerà N, Chaouachi K. Prevenzione dei danni da fumo di tabacco: un ruolo per l’islam? Tabaccologia 2007;1:20-21. http://www.tabaccologia.org/PDF/1_2007/4_12007.pdf <http://www.tabaccologia.org/PDF/1_2007/4_12007.pdf>
36. Chaouachi K. [E-Letter to the Editor] An Excellent Model for Adapting Tobacco Questionnaires. Journal of Epidemiology and Community Health 2007 (18 Jan). Comments on : Hanna L, Hunt S, Bhopal RS. Cross-cultural adaptation of a tobacco questionnaire for Punjabi,Cantonese, Urdu and Sylheti speakers: qualitative research for better clinical practice, cessation services and research. Journal of Epidemiology and Community Health 2006;60:1034-1039.
37. 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] 2010 (Feb); 18(1): 69-73 (online 23 Jul 2009). ISSN: 0943-1853 (Print) 1613-2238 (Online). doi : 10.1007/s10389-009-0272-7 http://www.springerlink.com/content/58352477706011t0/ <http://www.springerlink.com/content/58352477706011t0/>
38. Maziak W, Ward KD, Afifi Soweid RA, Eissenberg T. Tobacco smoking using a waterpipe: a re-emerging strain in a global epidemic. Tob Control 2004; 13: 327-333.
39. Chaouachi K. Hookah (Narghile, Shisha) Smoking and Communicable Diseases. Tabaccologia 2008;1: 47. http://tabaccologia.org/PDF/1_2008/18_12008.pdf <http://tabaccologia.org/PDF/1_2008/18_12008.pdf>
40. Meleigy M. Waterpipe and communicable diseases link, says WHO. The Lancet/Infections 2007;7:448.
41. Chaouachi K. [Comment] Hookah Smoking Harmfulness : Correcting a Few Errors and Clarifying Some Points of Interest. Tob Induc Dis. 2010 (20 Jan). A critical analysis of: Aljarrah K, Ababneh ZQ, Al-Delaimy WK. Perceptions of hookah smoking harmfulness: predictors and characteristics among current hookah users. Tob Induc Dis. 2009 Dec 18;5(1):16. [Epub ahead of print] http://www.tobaccoinduceddiseases.com/content/5/1/16/comments#385692 <http://www.tobaccoinduceddiseases.com/content/5/1/16/comments#385692>
42. Islami F, Pourshams A, Nasrollahzadeh D, Kamangar F, Fahimi S, Shakeri R, Abedi-Ardekani B, Merat S, Vahedi H, Semnani S, Abnet CC, Brennan P, Møller H, Saidi F, Dawsey SM, Malekzadeh R, Boffetta P. Tea drinking habits and oesophageal cancer in a high risk area in northern Iran: population based case-control study. BMJ. 2009 Mar 26;338:b929. http://www.bmj.com/cgi/content/full/338/mar26_2/b929 <http://www.bmj.com/cgi/content/full/338/mar26_2/b929>
43. Chaouachi K. [E-Letter] Hot Tea Drinking and Hookah Smoking in Iran. British Medical Journal 2009 (9 Oct) http://bmj.com/cgi/eletters/338/mar26_2/b929#222173 <http://bmj.com/cgi/eletters/338/mar26_2/b929#222173>
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47. Sansot Pierre: Du bon usage de la lenteur, Paris, Payot, 1998.
48. Hammond SK. Global patterns of nicotine and tobacco consumption. Handb Exp Pharmacol. 2009;(192):3-28.
49. Basham P. The DoH [UK Department of Health] is wrong about cessation. BMJ Blog 2010 (17 Mar). http://blogs.bmj.com/bmj/2010/03/17/patrick-basham-the-doh-is-wrong-about-cessation/?utm_source=feedburner&utm_medium=feed&utm_campaign=Feed%3A+bmj%2Fblogs+%28Latest+BMJ+blogs%29 <http://blogs.bmj.com/bmj/2010/03/17/patrick-basham-the-doh-is-wrong-about-cessation/?utm_source=feedburner&utm_medium=feed&utm_campaign=Feed%3A+bmj%2Fblogs+%28Latest+BMJ+blogs%29>
50. Chaouachi K. Prohibition Through the Hookah Looking Glass. Speech delivered at the second world conference of TICAP (The Tobacco International Coalition Against Prohibition)(Theme: “Are Guests Welcome? Prohibition and the Hospitality Industry”). 15 Mar 2010. Nieuwspoort; The Hague, The Netherlands. http://www.antiprohibition.org/ticap_pages.php?q=15 <http://www.antiprohibition.org/ticap_pages.php?q=15>
51. Chaouachi K. Culture matérielle et orientalisme. L’exemple d’une recherche socio-anthropologique sur le narguilé. [Eng.: Material Culture and Orientalism. The Example of a Socio-Anthropological Research on Narghile]. Arabica 2006, LIII;2: 177-209 [Published by Koninklijke Brill NV, Leiden, The Netherlands] http://www.ingentaconnect.com/content/brill/arab/2006/00000053/00000002/art00003 <http://www.ingentaconnect.com/content/brill/arab/2006/00000053/00000002/art00003>
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53. Neergaard J, Singh P, Job J, Montgomery S. Waterpipe smoking and nicotine exposure: A review of the current evidence. Nicotine Tob Res. 2007 Oct;9(10):987-94.
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57. 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. http://www.formindep.org/L-article-integral-du-professeur (English version) <http://www.formindep.org/L-article-integral-du-professeur>
58. Chaouachi K : Tout savoir sur le narguilé. Société, culture, histoire et santé [Eng.: Everything about Hookahs. Society, Culture, Origins and Health Aspects]. Paris: Maisonneuve et Larose, 2007, 256 pages, colour. ISBN : 978-2-7068-1954-4. http://www.amazon.fr/Tout-savoir-narguil%C3%A9-Kamal-Chaouachi/dp/2706819545 <http://www.amazon.fr/Tout-savoir-narguil%C3%A9-Kamal-Chaouachi/dp/2706819545>
60. Chaouachi K. [E-Letter] UK Ban on Smoking in General and on Hookah Smoking in Particular Should Not Stay. British Medical Journal 2009 (18 Mar) http://bmj.com/cgi/eletters/335/7609/20#210647 <http://bmj.com/cgi/eletters/335/7609/20#210647>
61. Chaouachi K. Hookah Smoking, Hot Tea Drinking, Contaminated Water and Oesophageal Cancer. European Journal of Cancer Correspondence published by ECCO (European CanCer Organisation). 9 March 2010. http://www.ecco-org.eu/News/News/EJC-Correspondence/Latest-Correspondence/Hookah-Smoking-Hot-Tea-Drinking-Contaminated-Wat/page.aspx/2160 <http://www.ecco-org.eu/News/News/EJC-Correspondence/Latest-Correspondence/Hookah-Smoking-Hot-Tea-Drinking-Contaminated-Wat/page.aspx/2160>
62. NassarAH, Abu-Musa A, Hannoun A, Usta IM. Authors’ reponse: nargile smoking and its effect on in vitro fertilization: a critical eye on the available literature , 12 July 2010. European Journal of Obstetrics & Gynecology and Reproductive Biology. September 2010 (Vol. 152, Issue 1, Page 116) http://www.ejog.org/article/S0301-2115%2810%2900207-1/abstract <http://www.ejog.org/article/S0301-2115(10)00207-1/abstract>