Raad - Effects of waterpipe tobacco smoking on lung function [CHEST]

DOI 10.1378/chest.10-0991 2011;139;764-774; Prepublished online July 29, 2010;Chest

Philippe Abou Jaoude, Roland Honeine and Elie A. AklDany Raad, Swarna Gaddam, Holger J. Schunemann, Jihad Irani, Meta-analysisFunction : A Systematic Review and Effects of Water-Pipe Smoking on Lung

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764

CHEST Original ResearchCOPD

Original Research

COPD as the fourth leading cause of mortality in the United States. 4

The causal relationship between long-term ciga-rette smoking and COPD is clearly established, 5-7

COPD is a preventable and treatable disease char-acterized by an abnormal infl ammatory response

of the lung to noxious particles or gases (eg, tobacco) leading to a progressive and nonreversible airfl ow obstruction. 1,2 COPD has become a leading cause

of mortality and morbidity throughout the world. The Global Burden of Disease study has projected that it will become the third leading cause of death by 2020. 3 The World Health Organization classifi es

Background: Although common in many Middle Eastern countries, water-pipe tobacco smoking, commonly known as water-pipe smoking (WPS), is increasingly popular in Western cultures. The primary objective of this study was to systematically review the effects of WPS on lung function. The secondary objective was to compare the effects of WPS and cigarette smoking on lung function. Methods: We conducted a systematic review using the approach of the Cochrane Collaboration to search for, select, and abstract studies. We conducted two separate meta-analyses comparing water-pipe smokers with nonsmokers, and water-pipe smokers with cigarette smokers for each of three spirometric measurements (FEV 1 , FVC, and FEV 1 / FVC). We used the standardized mean difference (SMD) to pool the results. Results: Six cross-sectional studies were eligible for this review. Compared with no smoking, WPS was associated with a statistically signifi cant reduction in FEV 1 (SMD 5 2 0.43; 95% CI, 2 0.58 to 2 0.29; equivalent to a 4.04% lower FEV 1 %), a trend toward lower FVC (SMD 5 2 0.15; 95% CI, 2 0.34 to 0.04; equivalent to a 1.38% reduction in FVC%), and lower FEV 1 / FVC (SMD 5 2 0.46; 95% CI, 2 0.93 to 0.01; equivalent to a 3.08% lower FEV 1 / FVC). Comparing WPS with cigarette smoking, there was no statistically signifi cant difference in FEV 1 , FVC, and FEV 1 / FVC. The six studies suffered from methodologic limitations. Conclusions: WPS negatively affects lung function and may be as harmful as cigarette smoking. WPS, therefore, is likely to be a cause of COPD. CHEST 2011; 139(4):764–774

Abbreviations: GRADE 5 Grading of Recommendations Assessment, Development and Evaluation; SMD 5 standardized mean difference; WPS 5 water-pipe smoking

Effects of Water-Pipe Smoking on Lung Function A Systematic Review and Meta-analysis

Dany Raad , MD ; Swarna Gaddam , MBBS, MPH ; Holger J. Schunemann, MD, PhD, FCCP ; Jihad Irani , MD, MPH ; Philippe Abou Jaoude , MD ; Roland Honeine , MD ; and Elie A. Akl, MD, PhD, MPH

Manuscript received April 18, 2010; revision accepted June 7, 2010. Affiliations: From the Department of Medicine (Drs Raad, Schunemann, Abou Jaoude, Honeine, and Akl), and the Depart-ment of Family Medicine (Drs Gaddam and Akl), State University of New York at Buffalo, Buffalo, NY; the Departments of Clinical Epidemiology and Biostatistics and Medicine (Drs Schunemann and Akl), McMaster University, Hamilton, ON, Canada; and the Faculty of Health Sciences (Dr Irani), University of Balamand, Beirut, Lebanon. Correspondence to: Elie A. Akl, MD, PhD, MPH, Department of Medicine, State University of New York at Buffalo, ECMC-CC 142, 462 Grider St, Buffalo, NY 14215; e-mail: [email protected]

© 2011 American College of Chest Physicians. Reproduction of this article is prohibited without written permission from the American College of Chest Physicians ( http://www.chestpubs.org/site/misc/reprints.xhtml ). DOI: 10.1378/chest.10-0991

For editorial comment see page 737


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www.chestpubs.org CHEST / 139 / 4 / APRIL, 2011 765

Data Abstraction

One reviewer abstracted data from each eligible study using a standardized and pilot-tested data abstraction form. A second reviewer verifi ed data abstraction. They resolved disagreements with the help of a third reviewer. The abstracted data included information about:

1. Study design and funding; 2. Population: setting and period, and participants’ characteristics; 3. Exposure: type, measurement tool, and exposure levels of

participants; 4. Outcomes: measurement tool and blinding of outcome

adjudicator; 5. Methodologic features: selection method, information col-

lection (measurement of exposure and outcome), handling of confounding, participation rate, and rate of complete data;

6. Statistical results.

We collected data separately for the three different exposure groups (water-pipe smokers, cigarette smokers, nonsmokers). FEV 1 , FVC, and FEV 1 /FVC were calculated as percentages of pre-dicted values and reported at the group level as mean and SD of these percentages.

Data Analysis

We calculated the k statistic to evaluate the agreement between the two reviewers assessing full texts for eligibility. For each of the three spirometric measurements (FEV 1 , FVC, and FEV 1 /FVC),

with cigarette smoking being the single most impor-tant risk factor. 6 A recent systematic review showed that the prevalence of COPD is highest among male smokers who are . 40 years old. 8

Water-pipe smoking (WPS) is a form of tobacco consumption that is increasing on a global level at a remarkable pace (see e-Appendix 1 and Fig 1 for further details on WPS). 9 The American Lung Association has described it as an “emerging deadly trend.” 10 In fact, a recent systematic review found WPS to be possibly associated with lung cancer, esophageal cancer, low birth weight, and periodontal diseases. 11

The above-referenced systematic review identifi ed no study assessing the association of WPS with air-ways diseases in general or COPD in particular. There are, however, published studies assessing the associa-tion of WPS with lung function measurements. Some of these measurements (ie, FEV 1 , FVC, FEV 1 /FVC) are considered valid surrogate measures of COPD. 12 In the absence of data on clinical disease, data on such surrogates may be useful for both clinical and research purposes. Thus, the primary objective of this study was to systematically review the effects of WPS on lung function. The secondary objective was to compare the effects of WPS and cigarette smoking on lung function.

Materials and Methods

Eligibility Criteria

We included studies that assessed the association between water-pipe tobacco use and lung function. Eligible studies had to include a group of individuals smoking a water pipe exclu-sively. They also had to include at least one of the following: (1) a group of nonsmokers, (2) a group of individuals practicing exclusively cigarette smoking. Our outcomes of interest were the following three spirometric measurements: FEV 1 , FVC, and FEV 1 /FVC.

Search Strategy

In June 2008, we searched the following electronic databases starting with their dates of inception: MEDLINE, EMBASE, and ISI the Web of Science. e-Appendix 2 provides the detailed search strategies. We also reviewed the reference lists of included and other relevant papers and used the Related Articles function in PubMed and applied no language restrictions.

Selection Process

Two reviewers independently screened titles and abstracts resulting from the search using a standardized screening guide. We obtained the full text of citations considered as potentially eli-gible by at least one of the two reviewers. Next, the two reviewers independently screened the full texts for eligibility using a stan-dardized and pilot tested form. Disagreements were resolved by discussion or by a third reviewer. Figure 1. Annotated fi gure of a water-pipe device.


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766 Original Research

as passive smokers in two of the studies. 19,21 All but one study included a group of cigarette smokers. 19 All studies reported spirometric measurements. Countries in which the studies were conducted were Turkey (n 5 3), Kuwait (n 5 1), Saudi Arabia (n 5 1), and Syria (n 5 1).

Methodologic Quality of Included Studies

The six included studies were cross-sectional and suffered from a number of methodologic limitations. All the studies used an objective outcome evalua-tion (measurement by spirometry). Authors calcu-lated the percent predicted spirometric values using the Communité Europeenne du Carbon e de l’Acier method in two studies, 17,20 and the Knudson and Hankinson methods in one study. 21 The remaining studies did not report any method. 16,18,19 None of the studies reported using a standardized exposure assess-ment tool. Selection of subjects was either done by visiting local coffee shops, 16,17,21 by volunteer recruit-ment, 18,19 or by a fi eld survey. 20 Only one study reported handling confounding by matching for gender 17 ; two other studies reported no difference between mean age for the groups involved. 19,21 Only one study reported blinding of outcome adjudicator, 16 and only one study reported the percentages of participation (88%) and complete data (96%). 20

we conducted two separate meta-analyses comparing water-pipe smokers with nonsmokers and water-pipe smokers with cigarette smokers. Because the populations and lung function measures differed across studies, we fi rst calculated the standardized mean difference (SMD) and 95% CI for each outcome in the indi-vidual studies. The SMD expresses a measurement in standard units rather than the original units of measurement. We then pooled the SMDs across studies using a random effects model. In a sensitivity analysis, we excluded studies in which the non-smokers were described as passive smokers. We translated the pooled SMD back into mean differences using the standard devi-ation for the respective spirometric outcomes derived from the National Health and Nutrition Examination Survey (NHANES) III data. 13

We tested results for homogeneity across studies using the I 2 test 14 and used the following interpretation of the value of I 2 : 0 to 50 5 low, 50 to 80 5 moderate and worthy of investigation, 80 to 100 5 severe and worthy of understanding, 95 to 100 5 aggre-gate with major caution (Julian Higgins, PhD, personal communi-cation). We rated the overall quality of evidence using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach. 15

Results

Description of Included Studies

Figure 2 shows the study fl ow. Of 1,658 identifi ed citations, we included six studies ( Table 1 ) 16-21 One study reported results separately for men and women. 18 All studies included a group of nonsmokers, described

Figure 2. Study fl ow diagram.




Tabl

e 1—

Cha

ract

eris

tics

of

Incl

ude

d St

udi

es M

easu

ring

the

Ass

ocia

tion

Bet

wee

n W

PS

and

Lu

ng F

unc

tion

Stud

y/Ye

ar

Popu

latio

nE

xpos

ure

Out

com

eM

etho

dolo

gic

Cha

ract

eris

tics

Res

ults

Kite

r et

al 17

/200

0

Stud

y de

sign

:

cr

oss-

sect

iona

l st

udy

F

undi

ng: n

ot

repo

rted

Al-F

ayez

et a

l 18 /1

988

St

udy

desi

gn:

cros

s-se

ctio

nal

stud

y

Fun

ding

: Kin

g

A

bdul

Azi

z C

ity

for

Scie

nce

and

Tech

nolo

gy

Sett

ing

and

peri

od: s

peci

al

cafe

s in

Izm

ir C

ity

(Tur

key)

, per

iod

not

repo

rted

Part

icip

ants

’ cha

ract

eris

tics:

30

2 su

bjec

ts, 1

00%

men

W

ater

-pip

e sm

oker

s:

82 s

ubje

cts,

ag

ed 5

6 6

10

y

Cig

aret

te s

mok

ers:

10

3 su

bjec

ts,

aged

46

6 1

4 y

W

ater

-pip

e sm

oker

s w

ho

quit

ciga

rett

e sm

okin

g:

95 s

ubje

cts,

ag

ed 5

4 6

12

y

Non

smok

ers:

117

sub

ject

s,

aged

46

6 1

6 y

Setti

ng a

nd p

erio

d: S

audi

Ara

bia,

pe

riod

not

rep

orte

dPa

rtic

ipan

ts’ c

hara

cter

istic

s:

59

5 su

bjec

ts,

men

age

d 20

-59

y an

d w

omen

17-

59 y

. Su

bjec

ts w

ith h

isto

ry o

f as

thm

a, c

hron

ic b

ronc

hitis

, or

any

car

diop

ulm

onar

y di

seas

es e

xclu

ded.

W

ater

-pip

e sm

oker

s:

344

subj

ects

, 73%

men

C

igar

ette

sm

oker

s:

251

subj

ects

, 75%

men

N

onsm

oker

s: 2

83 s

ubje

cts,

58

% m

en

Type

: wat

er p

ipe,

cig

aret

teM

easu

rem

ent:

self-

deve

lope

d

tool

, no

stan

dard

izat

ion

repo

rted

; per

sona

l in

terv

iew

W

ater

-pip

e cu

mul

ativ

e

cons

umpt

ion

mea

sure

d as

num

ber

of ju

rak-

year

s 5 am

ount

of

jura

k sm

oked

/d 3

num

ber

of s

mok

ing

year

s

Cig

aret

te c

umul

ativ

e

cons

umpt

ion

mea

sure

d as

pac

k-ye

ars 5

num

ber

of c

igar

ette

pac

ks

smok

ed/d

3 n

umbe

r of

sm

okin

g ye

ars

Exp

osur

e le

vels

of

pa

rtic

ipan

ts:

W

ater

-pip

e sm

oker

s:

47

6 3

3 ju

rak-

year

s

Wat

er-p

ipe

smok

ers

who

quit

ciga

rett

e sm

okin

g:

37 6

42

jura

k-ye

ars

and

38 6

32

pack

-yea

rs

Cig

aret

te sm

oker

s:

38 6

30 p

ack-

year

s

Type

: wat

er p

ipe,

cig

aret

teM

easu

rem

ent:

self-

de

velo

ped

tool

, no

stan

dard

izat

ion

repo

rted

; pe

rson

al in

terv

iew

Exp

osur

e le

vels

of

pa

rtic

ipan

ts: n

ot

repo

rted

Pulm

onar

y fu

nctio

n:

Mea

sure

men

t too

l:

po

rtab

le s

piro

met

er

acco

rdin

g to

the

stan

dard

s of

the

Am

eric

an T

hora

cic

soci

ety;

per

cent

age

pred

icte

d va

lues

ca

lcul

ated

au

tom

atic

ally

ac

cord

ing

to th

e C

omm

unité

E

urop

eenn

e du

Car

bon

e de

l’A

cier

met

hod

B

lindi

ng o

f out

com

e

ad

judi

cato

r: n

ot

repo

rted

Pulm

onar

y fu

nctio

n:

Mea

sure

men

t too

l: tim

e

re

volv

ing

spir

ogra

m

(Vita

logr

aph)

; met

hod

of c

alcu

latio

n of

pe

rcen

t pre

dict

ed

valu

es n

ot r

epor

ted

B

lindi

ng o

f out

com

e

ad

judi

cato

r: n

ot

repo

rted

Sele

ctio

n: w

ater

-pip

e

smok

ers

sele

cted

from

sp

ecia

l caf

es, c

igar

ette

sm

oker

s an

d no

nsm

oker

s se

lect

ed r

ando

mly

from

ca

fes

and

outs

ide

cafe

sIn

form

atio

n co

llect

ion:

obje

ctiv

e ou

tcom

e ev

alua

tion,

no

nsta

ndar

dize

d ex

posu

re

asse

ssm

ent t

ool

Con

foun

ding

han

dlin

g:

m

atch

ing

done

for

gend

er o

nly

% P

artic

ipat

ion:

not

rep

orte

d%

Com

plet

e da

ta: n

ot r

epor

ted

Sele

ctio

n: v

olun

teer

recr

uitm

ent

Info

rmat

ion

colle

ctio

n:

ob

ject

ive

outc

ome

eval

uatio

n,

nons

tand

ardi

zed

expo

sure

as

sess

men

t too

lC

onfo

undi

ng h

andl

ing:

no m

atch

ing

or a

djus

tmen

t in

the

anal

ysis

rep

orte

d%

Par

ticip

atio

n: n

ot

re

port

ed%

Com

plet

e da

ta: n

ot

re

port

ed

FE

V 1 ,

FV

C, a

nd F

EV

1 /FV

C

no

nsig

nifi c

antly

low

er in

w

ater

-pip

e sm

oker

s th

an

nons

mok

ers

FE

V 1 a

nd F

EV

1 /FV

C

si

gnifi

cant

ly lo

wer

in

ciga

rett

e sm

oker

s th

an

wat

er-p

ipe

smok

ers

FV

C n

onsi

gnifi

cant

ly lo

wer

in

ci

gare

tte

smok

ers

than

w

ater

-pip

e sm

oker

sT

here

was

neg

ativ

e co

rrel

atio

n

of p

ack-

year

s w

ith F

EV

1 in

ciga

rett

e sm

oker

s, b

ut

no c

orre

latio

n be

twee

n F

EV

1 and

jura

k-ye

ars

in w

ater

-pip

e sm

oker

s

FE

V 1 ,

FV

C, a

nd F

EV

1 /FV

C

si

gnifi

cant

ly lo

wer

in

wat

er-p

ipe

smok

ers

than

no

nsm

oker

sF

EV

1 and

FV

C s

igni

fi can

tly

lo

wer

in m

en

and

nons

igni

fi can

tly

low

er in

wom

en in

cig

aret

te

smok

ers

than

wat

er-p

ipe

smok

ers

FE

V 1 /F

VC

sig

nifi c

antly

low

er in

both

men

and

wom

en in

ci

gare

tte

smok

ers

than

w

ater

-pip

e sm

oker

sH

eavy

wat

er-p

ipe

smok

ers

( .

2 w

ater

pip

e/d)

exh

ibite

d (C

ontin

ued)


www.chestpubs.org



Stud

y/Ye

ar

Popu

latio

nE

xpos

ure

Out

com

eM

etho

dolo

gic

Cha

ract

eris

tics

Res

ults

a m

arke

d de

clin

e in

FE

V 1

and

FE

V 1 /F

VC

com

pare

d w

ith li

ght s

mok

ers

(1-2

wat

er p

ipe/

d)

Tabl

e 1—

(Con

tinu

ed)

Al M

utai

ri

et a

l 16 /2

006

St

udy

desi

gn:

cros

s-se

ctio

nal

stud

y

Fun

ding

: Kuw

ait

Uni

vers

ity

Res

earc

h A

dmin

istr

atio

n G

rant

Ayd

in e

t al 19

/200

4

Stud

y de

sign

:

cr

oss-

sect

iona

l st

udy

F

undi

ng:

not r

epor

ted

Sett

ing

and

peri

od: l

ocal

co

ffee

sho

ps a

nd u

nive

rsity

st

uden

ts in

Kuw

ait,

peri

od

not r

epor

ted

Part

icip

ants

’ cha

ract

eris

tics:

16

8 su

bjec

ts, a

ll su

bjec

ts

who

sm

oked

mor

e th

an

one

kind

of t

obac

co, h

ad

chro

nic

card

iopu

lmon

ary

or r

enal

dis

ease

s, o

r w

ere

on r

egul

ar m

edic

atio

ns

wer

e ex

clud

ed fr

om

the

stud

y

Wat

er-p

ipe

smok

ers:

77

sub

ject

s, 9

0% m

en,

aged

36.

97

(34.

79-3

9.16

) y

Cig

aret

te s

mok

ers:

75

sub

ject

s, 9

3% m

en,

aged

37.

73 (3

5.54

-39.

95) y

N

onsm

oker

s: 16

subj

ects

,

56

% m

en, a

ged

33.3

(2

8.9-

37.7

6) y

Sett

ing

and

peri

od: T

urke

y,

peri

od n

ot r

epor

ted

Part

icip

ants

’ cha

ract

eris

tics:

25

sub

ject

s, a

ll su

bjec

ts

had

no s

igni

fi can

t lun

g or

ot

her

syst

em d

isea

se o

r ci

gare

tte

smok

ing

hist

ory

W

ater

-pip

e sm

oker

s:

14 s

ubje

cts,

100

% m

en,

aged

53.

7 6

9.8

y

Type

: wat

er p

ipe,

cig

aret

teM

easu

rem

ent:

self-

deve

lope

d

tool

, no

stan

dard

izat

ion

repo

rted

; con

stru

cted

qu

estio

nnai

re th

at id

entifi

es

smok

ing

beha

vior

of b

oth

grou

ps, d

etai

ling

rate

of

cons

umpt

ion

of to

bacc

o/d

Obj

ectiv

e m

easu

rem

ent t

ool:

ur

inar

y co

tinin

e an

d ni

cotin

e le

vel

Exp

osur

e le

vels

of p

artic

ipan

ts:

W

ater

-pip

e sm

oker

s:

A

ge o

f sta

rtin

g sm

okin

g:

24

.89

(22.

61-2

7.17

) y

U

rina

ry n

icot

ine

5 4

40.4

8

(197

.06-

683.

91) n

g/m

L

U

rina

ry c

otin

ine

5 6

77.6

2

(458

.89-

896.

34) n

g/m

L

Cig

aret

te s

mok

ers:

Age

of s

tart

ing

smok

ing:

20.3

6 (1

8.55

-22.

17 5

8) y

Uri

nary

nic

otin

e 5

148

7.30

(839

.26-

2135

.37)

ng/

mL

Uri

nary

cot

inin

e 5

132

1.35

(100

3.73

-163

8.98

) ng/

mL

Type

: wat

er p

ipe

Mea

sure

men

t: se

lf-de

velo

ped

to

ol, n

o st

anda

rdiz

atio

n re

port

ed; p

erso

nal i

nter

view

Exp

osur

e le

vels

of p

artic

ipan

ts:

W

ater

-pip

e sm

oker

s: 2

3.7

6 8

.7 y

Pa

ssiv

e sm

oker

s: 2

1.3

6 5

.2 y

Pulm

onar

y fu

nctio

n:

Mea

sure

men

t too

l:

Ja

eqar

Mas

terl

ab

spir

omet

ry; m

etho

d of

cal

cula

tion

of

perc

enta

ge p

redi

cted

va

lues

not

rep

orte

dB

lindi

ng o

f out

com

e

ad

judi

cato

r: y

es

Pulm

onar

y fu

nctio

n:

Mea

sure

men

t too

l:

Se

nsor

Med

ia

V m

ax 2

2; m

etho

d of

cal

cula

tion

of

perc

enta

ge p

redi

cted

va

lues

not

rep

orte

d

Blin

ding

of o

utco

me

adju

dica

tor:

no

t rep

orte

d

Sele

ctio

n: s

ubje

cts

se

lect

ed fr

om lo

cal c

offe

e sh

ops

and

amon

g un

iver

sity

stu

dent

sIn

form

atio

n co

llect

ion:

obje

ctiv

e ou

tcom

e ev

alua

tion,

no

nsta

ndar

dize

d ex

posu

re

asse

ssm

ent

tool

Con

foun

ding

han

dlin

g: n

o

mat

chin

g or

adj

ustm

ent

in th

e an

alys

is r

epor

ted

% P

artic

ipat

ion:

not

repo

rted

% C

ompl

ete

data

: not

repo

rted

Sele

ctio

n: v

olun

teer

rec

ruitm

ent

Info

rmat

ion

colle

ctio

n:

ob

ject

ive

outc

ome

eval

uatio

n,

nons

tand

ardi

zed

expo

sure

as

sess

men

t too

lC

onfo

undi

ng h

andl

ing:

mat

chin

g no

t rep

orte

d bu

t no

sign

ifi ca

nt

diff

eren

ce b

etw

een

the

mea

n ag

e of

the

two

grou

ps

FE

V 1 a

nd F

EV

1 /FV

C

no

nsig

nifi c

antly

low

er in

w

ater

-pip

e sm

oker

s th

an n

onsm

oker

sF

EV

1 , F

VC

, and

FE

V 1 /F

VC

nons

igni

fi can

tly lo

wer

in

wat

er-p

ipe

smok

ers

than

ci

gare

tte

smok

ers

The

re w

as n

o si

gnifi

cant

diff

eren

ce in

FE

V 1 a

nd

FE

V 1 /F

VC

val

ues

in r

elat

ion

to d

urat

ion

of s

mok

ing

( , 1

0 y

vs .

10

y) in

bot

h ci

gare

tte

and

wat

er-p

ipe

smok

ers

FE

V 1 ,

FV

C, a

nd F

EV

1 /FV

C

no

nsig

nifi c

antly

low

er in

w

ater

-pip

e sm

oker

s th

an

nons

mok

ers

(Con

tinue

d)




Tabl

e 1—

(Con

tinu

ed)

Moh

amm

ad

et a

l 20 /2

008

St

udy

desi

gn:

cros

s-se

ctio

nal

stud

y

Fun

ding

:

no

t rep

orte

d

Kös

eo ğ�lu

et a

l 21 /2

006

St

udy

desi

gn:

cros

s-se

ctio

nal

stud

yF

undi

ng:

not r

epor

ted

Sett

ing

and

peri

od: S

yria

,

fi r

st s

emes

ter

of 1

994-

1995

Part

icip

ants

’ cha

ract

eris

tics:

25

4 su

bjec

ts, 1

00%

wom

en,

no c

omor

bidi

ty, n

o re

spir

ator

y sy

mpt

oms

rela

ted

to fa

ctor

s ot

her

than

sm

okin

g, a

nd n

o ex

posu

re to

oth

er r

isk

fact

ors

in h

er d

aily

life

; no

ne o

f the

sub

ject

s sm

oked

bot

h w

ater

pip

e an

d ci

gare

ttes

W

ater

-pip

e sm

oker

s:

77 s

ubje

cts,

ag

ed 4

0.99

6 1

2.54

y

Cig

aret

te sm

oker

s: 77

subj

ects

,

ag

ed 4

4.84

6 1

0.55

y

Non

smok

ers:

100

sub

ject

s,

aged

39.

13 6

12.

898

y

Sett

ing

and

peri

od: l

ocal

cof

fee

shop

s in

Izm

ir C

ity

(Tur

key)

, per

iod

not

repo

rted

Part

icip

ants

’ cha

ract

eris

tics:

58

sub

ject

s, a

ll su

bjec

ts w

ho

had

hist

ory

of s

yste

mic

or

pulm

onar

y di

seas

e, C

OPD

, lu

ng c

ance

r, pr

evio

us lu

ng

surg

ery,

com

mon

col

d or

vi

ral r

espi

rato

ry d

isea

se,

alle

rgy

hist

ory,

his

tory

of a

ctiv

e pu

lmon

ary

infe

ctio

n, o

r ta

king

m

edic

atio

ns th

at in

crea

se

or d

ecre

ase

muc

ocili

ary

clea

ranc

e w

ere

excl

uded

Type

: wat

er p

ipe,

cig

aret

teM

easu

rem

ent:

self-

deve

lope

d

pilo

t-te

sted

tool

, no

furt

her

valid

atio

n re

port

ed

Wat

er-p

ipe

cum

ulat

ive

co

nsum

ptio

n ca

lcul

ated

usin

g:

Q 5

S 3

q (g

) 3 T

(d)/

1,00

0

Cig

aret

te c

umul

ativ

e

cons

umpt

ion

calc

ulat

ed u

sing

: Q

5 N

(g) 3

T (d

)/1,

000

Exp

osur

e le

vels

of p

artic

ipan

ts:

W

ater

-pip

e sm

oker

s: 5

8 6

3.8

kg,

60 6

3.8

1 y

C

igar

ette

sm

oker

s: 4

0 6

3.8

kg,

38 6

3.8

1 y

Type

: wat

er p

ipe,

cig

aret

teM

easu

rem

ent:

self-

deve

lope

d

tool

, no

stan

dard

izat

ion

repo

rted

; per

sona

l int

ervi

ewO

bjec

tive

mea

sure

men

t too

l

(uri

nary

cot

inin

e le

vel)

Exp

osur

e le

vels

of p

artic

ipan

ts:

W

ater

-pip

e sm

oker

s:

A

vera

ge a

mou

nt

of

toba

cco

5 3

5.5

6 2

2.8/

y

U

rina

ry c

otin

ine

5

83

8.9

6 7

62.5

ng/

mL

C

igar

ette

sm

oker

s:

Pulm

onar

y fu

nctio

n:

Mea

sure

men

t too

l:

au

tom

atic

cal

ibra

ted

spir

omet

er;

perc

ent p

redi

cted

va

lues

cal

cula

ted

auto

mat

ical

ly

acco

rdin

g to

the

Com

mun

ité E

urop

eenn

e du

Car

bon

e de

l’A

cie

met

hod

B

lindi

ng o

f out

com

e

ad

judi

cato

r:

not r

epor

ted

F

EV

1 : co

nsid

ered

ab

norm

al o

f , 8

0%

FE

V 1 /F

VC

: con

side

red

to r

efl e

ct o

bstr

uctio

n if

, 7

0%

Pulm

onar

y fu

nctio

n:

Mea

sure

men

t too

l:

sp

irom

eter

(Sen

sor

Med

ics

V-M

ax)

acco

rdin

g to

the

Am

eric

an T

hora

cic

Soci

ety;

per

cent

age

pred

icte

d va

lues

ca

lcul

ated

acc

ordi

ng

to K

nuds

on a

nd

Han

kins

on m

etho

dsB

lindi

ng o

f out

com

e

ad

judi

cato

r:

not r

epor

ted

Sele

ctio

n: s

ubje

cts

re

crui

ted

by fi

eld

surv

eyIn

form

atio

n co

llect

ion:

obje

ctiv

e ou

tcom

e ev

alua

tion,

non

stan

dard

ized

ex

posu

re a

sses

smen

t too

lC

onfo

undi

ng h

andl

ing:

no m

atch

ing

or a

djus

tmen

t in

the

anal

ysis

rep

orte

d%

Par

ticip

atio

n: 8

8%

Com

plet

e da

ta: 9

6

Sele

ctio

n: s

ubje

cts

se

lect

ed fr

om lo

cal

coff

ee s

hops

Info

rmat

ion

colle

ctio

n:

ob

ject

ive

outc

ome

eval

uatio

n,

nons

tand

ardi

zed

expo

sure

as

sess

men

t too

lC

onfo

undi

ng h

andl

ing:

mat

chin

g no

t rep

orte

d,

no s

igni

fi can

t diff

eren

ce in

age

s,

BM

I, a

nd p

ulm

onar

y fu

nctio

n te

st p

aram

eter

s%

Par

ticip

atio

n: n

ot r

epor

ted

% C

ompl

ete

data

: not

rep

orte

d

FE

V 1 ,

FV

C, a

nd F

EV

1 /FV

C

si

gnifi

cant

ly lo

wer

in

wat

er-p

ipe

smok

ers

than

no

nsm

oker

sF

EV

1 , F

VC

, and

FE

V 1 /F

VC

sign

ifi ca

ntly

low

er in

ci

gare

tte

smok

ers

than

wat

er-p

ipe

smok

ers

The

re w

as a

neg

ativ

e co

rrel

atio

n

for

cum

ulat

ive

quan

tity

of

both

cig

aret

te a

nd W

PS w

ith

FE

V 1 ,

FV

C, a

nd F

EV

1 /FV

C.

FE

V 1 ,

FV

C, a

nd F

EV

1 /FV

C

no

nsig

nifi c

antly

low

er in

w

ater

-pip

e sm

oker

s th

an

nons

mok

ers

FE

V 1 ,

FV

C, a

nd F

EV

1 /FV

C

no

nsig

nifi c

antly

low

er in

ci

gare

tte

smok

ers

than

w

ater

-pip

e sm

oker

s

Stud

y/Ye

ar

Popu

latio

nE

xpos

ure

Out

com

eM

etho

dolo

gic

Cha

ract

eris

tics

Res

ults

Pa

ssiv

e sm

oker

s: d

efi n

ed

as in

divi

dual

s w

ho d

o no

t sm

oke

but a

re e

xpos

ed to

in

tens

ive

ciga

rett

e sm

oke

in th

e liv

ing

or w

orki

ng

envi

ronm

ent:

11 s

ubje

cts,

91

% m

en, a

ged

43.8

6 1

2.9

y

% P

artic

ipat

ion:

not

repo

rted

% C

ompl

ete

data

: not

repo

rted

(Con

tinue

d)


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Tabl

e 1—

(Con

tinu

ed)

Stud

y/Ye

ar

Popu

latio

nE

xpos

ure

Out

com

eM

etho

dolo

gic

Cha

ract

eris

tics

Res

ults

W

ater

-pip

e sm

oker

s:

20 s

ubje

cts,

age

d 56

.1 6

8.4

y

Cig

aret

te s

mok

ers:

23

sub

ject

s, a

ged

52.0

6 5

.7 y

Pa

ssiv

e sm

oker

s: 1

5 su

bjec

ts,

aged

54.

5 6

19

y

Ave

rage

am

ount

of to

bacc

o 5

36.

2 6

23.

1 pa

ck-y

ears

Uri

nary

cot

inin

e 5

1,57

6 6

974

.9 n

g/m

L

Dat

a ar

e pr

esen

ted

as m

ean

6 S

D u

nles

s ot

herw

ise

indi

cate

d. J

urak

5 ty

pe o

f tob

acco

pas

te th

at c

onta

ins

vari

ous

spic

es a

nd d

ried

frui

ts; N

5 n

umbe

r of

cig

aret

tes/

d; Q

5 cu

mul

ativ

e qu

antit

y sm

oked

, kg;

q

5 q

uant

ity s

mok

ed p

er s

essi

on, g

; S 5

num

ber

of s

essi

ons/

d; T

5 d

urat

ion

of s

mok

ing,

d; W

PS 5

wat

er-p

ipe

smok

ing.

WPS Compared With Nonsmoking

The pooled SMD for FEV 1 was 2 0.43 (95% CI, 2 0.58 to 2 0.29; I 2 5 24%) equivalent to a 4.04% lower FEV 1 % value in the water-pipe group ( Fig 3 ). In the sensitivity analysis excluding studies in which the nonsmokers were described as passive smokers, the pooled SMD remained statistically signifi cant at 2 0.46 (95% CI, 2 0.60 to 2 0.31; I 2 5 21%). The SMD for FVC was 2 0.15 (95% CI, 2 0.34 to 0.04; I 2 5 0%), equivalent to a 1.38% reduction in FVC% in the water-pipe group ( Fig 4 ). In the sensitivity analysis, the pooled SMD was 2 0.19 (95% CI, 2 0.40 to 0.01; I 2 5 0%). The SMD for FEV 1 /FVC was 2 0.46 (95% CI, 2 0.93 to 0.01; I 2 5 92%), suggesting a lower per-cent predicted value in the water-pipe group, by 3.08% ( Fig 5 ). In the sensitivity analysis, the pooled mean difference was 2 0.51 (95% CI, 2 1.06 to 0.05; I 2 5 94%). The GRADE overall quality of evidence for FEV 1 was moderate; it was downgraded secondary to study limitations.

WPS Compared With Cigarette Smoking

The pooled SMD for FEV 1 between the two groups was 0.20 (95% CI. 2 0.15 to 0.55; I 2 5 87%), which translates into a nonsignifi cantly lower FEV 1 % by 1.88% in the cigarette smoking group ( Fig 6 ). The SMD for FVC between the two groups was 0.27 (95% CI, 0.09-0.44; I 2 5 83%), which translates into a signifi -cantly lower percentage predicted value in the ciga-rette smoking group, by 2.48% ( Fig 7 ). The SMD in FEV 1 /FVC between the two groups was 0.22 (95% CI, 2 0.29 to 0.73; I 2 5 94%), suggesting a nonsignifi -cantly lower percentage predicted value (1.47%) in the water-pipe group ( Fig 8 ). The GRADE overall quality of evidence for FEV 1 was low; it was downgraded secondary to study limitations and imprecision.

Association Between the Duration of WPS and Lung Function

Four studies reporting on the association between the duration of WPS and lung function had mixed results. Two studies reported no correlation between the duration of WPS and the decline in FEV 1 . 16,17 The other two studies reported an association; one found a marked decline in FEV 1 and FEV 1 /FVC when comparing heavy smokers ( . 2 water pipe/d) with light smokers (1-2 water pipe/d), whereas the other reported a negative correlation for cumulative quan-tity of WPS with FEV 1 , FVC, and FEV 1 /FVC.

Discussion

We systematically reviewed the scientifi c literature for the effects of WPS on lung function. Compared




smoking patterns, frequency and lengths of smoking sessions, the type and quality of tobacco used for both WPS and cigarette smoking). This is particu-larly problematic given the potential variability in exposure. Finally, all but two studies failed to distin-guish passive smokers from nonsmokers for expo-sure to WPS or cigarette smoking. However, the results of sensitivity analyses excluding these two studies were consistent with the results of the main analyses.

The association between WPS and reduction in FEV 1 is not only statistically signifi cant but also of potential clinical relevance. We can assess the clinical relevance comparing the effect size to the minimal important difference, defi ned as “the smallest differ-ence in score in the outcome of interest that informed patients or informed proxies perceive as important, either benefi cial or harmful, and which would lead the patient or clinician to consider a change in manage-ment.” It has been suggested that the minimal impor-tant difference for FEV 1 is in the range of 100 to 140 mL. 22 The mean difference in our study was estimated to be around 4%, which approximates to 173 mL for a 40-year-old white man of 180 cm height. Therefore, the reduction of FEV 1 associated with WPS is clinically relevant.

The association of WPS with a signifi cant reduc-tion in FEV 1 suggests its implication as a risk factor for obstructive disease. This is consistent with the fi nding of a trend toward reduction in FVC and FEV 1 /FVC among water-pipe smokers. The lack of statistical signifi cance for these reductions is likely due to the lack of statistical power. Taken together,

with no smoking, WPS was associated with a statisti-cally signifi cant reduction of FEV 1 and a trend toward lower FVC and FEV 1 /FVC. The quality of evidence is moderate (ie, further research is likely to have an important impact on our confi dence in the estimate of effect and may change the estimate). 15 There were no statistically signifi cant differences in FEV 1 and FEV 1 /FVC between water-pipe smokers and cigarette smokers. The quality of evidence was low (ie, further research is very likely to have an important impact on our confi dence in the estimate of effect and is likely to change the estimate). 15

Our study has a number of strengths. First, we used the comprehensive approach of Cochrane Col-laboration for conducting systematic reviews, includ-ing a very sensitive search strategy, a duplicate and independent selection and data abstraction processes, and a rigorous evaluation of study methodological quality. Also, by pooling results across studies we were able to obtain relatively precise estimates of the outcomes of interest. Last, this is the fi rst meta-analysis, to our knowledge, that assesses the associa-tion of WPS with lung function.

The study also has a number of limitations. Although the primary objective of this study was to assess the effects of WPS on lung function, the avail-able data from cross-sectional studies provide evi-dence for an association but does not establish causality. Our confi dence in the results of the meta-analysis is reduced by the methodologic limitations of the included individual studies. Indeed, none of the studies used a standardized tool to measure the degree of exposures of interest (eg, in terms of

Figure 3. Comparison of FEV 1 in water-pipe smokers and nonsmokers. Al Fayez 1988 A includes only the male participants; Al Fayez 1988 B includes only the female participants. IV 5 inverse variance; Std 5 standard.

Figure 4. Comparison of FVC in water-pipe smokers and nonsmokers. See Figure 3 legend for expansion of abbreviations.


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however, these fi ndings suggest a possible role of WPS in the development of COPD.

There is additional evidence of the implication of WPS in COPD. Two studies using questionnaires adapted from the Medical Research Council 16 and the European Coal and Steel Community 20 on the symptoms of chronic bronchitis identifi ed statisti-cally signifi cant higher number of positive responses in water-pipe smokers than in cigarette smokers. In the fi rst study, symptoms of chronic bronchitis were identifi ed in 11.75% of water-pipe smokers, as com-pared with 9.5% of cigarette smokers, and 0% in non-smokers. 16 In the second study, chronic bronchitis was found to be more prevalent in water-pipe smokers than cigarette smokers for cumu lative quantity and duration. 20 Despite the limited available data, these results help add up to the evidence of the risk of devel-opment of COPD in water-pipe smokers.

Although the results of FEV 1 and FEV 1 /FVC com-paring WPS to cigarette smoking show no statistical difference, they suffered from a high level of hetero-geneity. The most likely explanation for this hetero-geneity is the variation of levels of exposure to the two forms of smoking. Although the effect on lung function is associated with the levels of exposure to cigarette smoking and (likely) WPS, the degree of exposure was not measured. It is also possible that that the lack of observed difference between water-pipe smokers and cigarette smokers may be because of inadequate power.

Figure 5. Comparison of FEV 1 /FVC in water-pipe smokers and nonsmokers. Al Fayez 1988 A includes only the male participants; Al Fayez 1988 B includes only the female participants. See Figure 3 legend for expansion of abbreviations.

Figure 6. Comparison of FEV 1 in water-pipe smokers and cigarette smokers. Al Fayez 1988 A includes only the male participants; Al Fayez 1988 B includes only the female participants. See Figure 3 legend for expansion of abbreviations.

Some authors have hypothesized a less important effect of WPS compared with cigarette smoking on lung function based on a number of assumptions: the inability of smoke to reach the lower airways because of the smoking pattern and because of the fi ltration of smoke by the water and a better healing of small air-way infl ammation because of intermittent nature of smoking. 17,19 Our study found no statistically signifi -cant difference in FEV 1 and FEV 1 /FVC between the two forms of smoking. Indeed, recent evidence has shown that water does not signifi cantly fi lter out the nicotinic products produced by WPS. 23 Also, water-pipe smokers have an elevation in the level of parameters of oxidation injury and a decreased total antioxidant activity. 24,25 The resulting oxidative stress is believed to play an important role in the pathogenesis of COPD. 1

Conclusions

Implications for Public Health Policy

This study adds to the rapidly growing evidence of the association of WPS with deleterious health out-comes, 11 which has very important implications for both clinical and public health practice. Spirometry performance might give the clinician an opportunity to convince smokers to quit. 26 More importantly, our study supplies the physician with data they might use in counseling patients about the deleterious effect of




Dr Abou Jaoude: contributed to screening titles, abstracts, and full texts; revising the article critically for important intellectual content; and approving the fi nal version of this manuscript. Dr Honeine: contributed to screening titles, abstracts, and full texts; revising the article critically for important intellectual con-tent; and approving the fi nal version of this manuscript. Dr Akl: contributed to drafting the protocol, designing the search strategy, developing the forms, screening, data abstraction, data analysis, data interpretation, drafting of the manuscript, revising the article critically for important intellectual content, and approv-ing the fi nal version of this manuscript. Financial/nonfi nancial disclosures: The authors have reported to CHEST that no potential confl icts of interest exist with any companies/organizations whose products or services may be dis-cussed in this article. Other contributions: We thank Ann Grifasi for her adminis-trative assistance, Drs Monique Chaaya, Yousser Mohammad, Sana Al Mutairi, and Nalan Koseoglu for their correspondence with results, and Dr Sameer Gunukula for his help in formatting the table. Additional information: The e-Appendices can be found in the Online Supplement at http://chestjournal.chestpubs.org/content/139/4/764/suppl/DC1.

References 1. Global Initiative for Obstructive Lung Disease . 2009 . Global

strategy for the diagnosis, management, and prevention of chronic obstructive pulmonary disease. Updated 2009. Based on April 1998 NHLBI/WHO workshop. http://www.goldcopd.com/Guidelineitem.asp?l1=2&l2=1&intId=2003. Accessed July 26, 2010.

2 . Rabe KF , Hurd S , Anzueto A , et al ; Global Initiative for Chronic Obstructive Lung Disease . Global strategy for the diagnosis, management, and prevention of chronic obstruc-tive pulmonary disease: GOLD executive summary . Am J Respir Crit Care Med . 2007 ; 176 ( 6 ): 532 - 555 .

3 . Lopez AD , Shibuya K , Rao C , et al . Chronic obstructive pulmonary disease: current burden and future projections . Eur Respir J . 2006 ; 27 ( 2 ): 397 - 412 .

4 . World Health Organization. World Health Report . http://www.who.int/whr/2000/en/whr00_annex_en.pdf. Accessed July 26, 2010.

WPS on lung function. As for the public health prac-tice, this study illustrates that WPS may be as harmful as cigarette smoking in terms of lung function. Public health policy makers need to aggressively address the epidemic of WPS to raise awareness and advo-cate for appropriate policy changes.

Implications for Research

As advised by the World Health Organization, there is a need for more research related to WPS. 27 Spe-cifi cally, there is a need for higher-quality prospec-tive studies that could more clearly identify the causal relationship between WPS and clinical out-comes. Similarly, there is a need for exploring whether quitting smoking slows down or reverses the deterio-ration of lung function. Finally, researchers need to focus on standardizing the exposure measurement tools in order to reliably assess for dose-response relationships. 28

Acknowledgments Author contributions: Dr Raad: contributed to study selec-tion, data abstraction, data analysis, data interpretation, draft-ing of the manuscript, revising the article critically for impor-tant intellectual content, and approving the fi nal version of this manuscript. Dr Gaddam: contributed to study data abstraction, revising the article critically for important intellectual content, and approving the fi nal version of this manuscript. Dr Schunemann: contributed to data interpretation, revising the article critically for important intellectual content, and approving the fi nal version of this manuscript. Dr Irani: contributed to drafting the protocol and designing the search strategy, revising the article critically for important intellectual content, and approving the fi nal version of this manu-script.

Figure 7. Comparison of FVC in water-pipe smokers and cigarette smokers. See Figure 3 legend for expansion of abbreviations.

Figure 8. Comparison of FEV 1 /FVC in water-pipe smokers and cigarette smokers. Al Fayez 1988 A includes only the male participants; Al Fayez 1988 B includes only the female participants. See Figure 3 legend for expansion of abbreviations.


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5 . Marco M , Minette A . Lung function changes in smokers with normal conventional spirometry . Am Rev Respir Dis . 1976 ; 114 ( 4 ): 723 - 738 .

6 . Sherman CB . The health consequences of cigarette smok-ing. Pulmonary diseases . Med Clin North Am . 1992 ; 76 ( 2 ): 355 - 375 .

7 . Milic-Emili J . Measurement of “closing volume” as a simple and sensitive test for early detection of small airway obstruc-tion . Ann N Y Acad Sci . 1974 ; 221 : 115 - 116 .

8 . Halbert RJ , Natoli JL , Gano A , Badamgarav E , Buist AS , Mannino DM . Global burden of COPD: systematic review and meta-analysis . Eur Respir J . 2006 ; 28 ( 3 ): 523 - 532 .

9 . Cobb C , Ward KD , Maziak W , Shihadeh AL , Eissenberg T . Waterpipe tobacco smoking: an emerging health crisis in the United States . Am J Health Behav . 2010 ; 34 ( 3 ): 275 - 285 .

10. An emerging deadly trend : waterpipe tobacco use: American Lung Association 2007 . http://slati.lungusa.org/reports/Trend%20Alert_Waterpipes.pdf . Accessed July 26, 2010.

11 . Akl EA , Gaddam S , Gunukula SK , et al . The effects of water-pipe tobacco smoking on health outcomes: a systematic review. Int J Epidemiol . 2010 ; 39 ( 3 ): 834 - 857 .

12 . Soriano JB , Visick GT , Muellerova H , Payvandi N , Hansell AL . Patterns of comorbidities in newly diagnosed COPD and asthma in primary care . Chest . 2005 ; 128 ( 4 ): 2099 - 2107 .

13 . Hankinson JL , Odencrantz JR , Fedan KB . Spirometric refer-ence values from a sample of the general U.S. population . Am J Respir Crit Care Med . 1999 ; 159 ( 1 ): 179 - 187 .

14 . Higgins JPT , Thompson SG , Deeks JJ , Altman DG . Measur-ing inconsistency in meta-analyses . BMJ . 2003 ; 327 ( 7414 ): 557 - 560 .

15 . Schünemann HJ , Jaeschke R , Cook DJ , et al ; ATS Documents Development and Implementation Committee . An offi cial ATS statement: grading the quality of evidence and strength of recommendations in ATS guidelines and recommenda-tions . Am J Respir Crit Care Med . 2006 ; 174 ( 5 ): 605 - 614 .

16 . Al Mutairi SS , Shihab-Eldeen AA , Mojiminiyi OA , Anwar AA . Comparative analysis of the effects of hubble-bubble (sheesha) and cigarette smoking on respiratory and metabolic param-eters in hubble-bubble and cigarette smokers . Respirology . 2006 ; 11 ( 4 ): 449 - 455 .

17 . Kiter G , Uçan ES , Ceylan E , Kilinç O . Water-pipe smoking and pulmonary functions . Respir Med . 2000 ; 94 ( 9 ): 891 - 894 .

18 . Al-Fayez SF , Salleh M , Ardawi M , Zahran FM . Effects of sheesha and cigarette smoking on pulmonary function of Saudi males and females . Trop Geogr Med . 1988 ; 40 ( 2 ): 115 - 123 .

19 . Aydin A , Kiter G , Durak H , Ucan ES , Kaya GC , Ceylan E . Water-pipe smoking effects on pulmonary permeability using technetium-99m DTPA inhalation scintigraphy . Ann Nucl Med . 2004 ; 18 ( 4 ): 285 - 289 .

20 . 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 - 414 .

21 . Köseo ğ�lu N , Aydin A , Uçan ES , et al . The effects of water-pipe, cigarette and passive smoking on mucociliary clearance [in Turkish]. Tuberk Toraks . 2006 ; 54 ( 3 ): 222 - 228 .

22 . Cazzola M , MacNee W , Martinez FJ , et al ; American Thoracic Society ; European Respiratory Society Task Force on out-comes of COPD . Outcomes for COPD pharmacological trials: from lung function to biomarker . Eur Respir J . 2008 ; 31 ( 2 ): 416 - 469 .

23 . Neergaard J , Singh P , Job J , Montgomery S . Waterpipe smok-ing and nicotine exposure: a review of the current evidence . Nicotine Tob Res . 2007 ; 9 ( 10 ): 987 - 994 .

24 . Al-Numair K , Barber-Heidal K , At-Assaf A , et al . Water-pipe (shisha) smoking infl uences total antioxidant capacity and oxidative stress of healthy Saudi males . Journal of Food, Agriculture, and Environment . 2007 ; 5 ( 3-4 ): 17 - 22 .

25 . Wolfram RM , Chehne F , Oguogho A , Sinzinger H . Narghile (water pipe) smoking infl uences platelet function and (iso-)eicosanoids . Life Sci . 2003 ; 74 ( 1 ): 47 - 53 .

26 . Ferguson GT , Enright PL , Buist AS , Higgins MW . Offi ce spirometry for lung health assessment in adults: A consen-sus statement from the National Lung Health Education Program . Chest . 2000 ; 117 ( 4 ): 1146 - 1161 .

27 . WHO study group on Tobacco Product Regualation (TobReg) . Advisory Note. Waterpipe tobacco smoking: health effects, research needs and recommended actions by regu lators. http://www.who.int/tobacco/global_interaction/tobreg/Waterpipe%20recommendation_Final.pdf . Accessed July 26, 2010.

28 . Maziak W , Ward KD , Afi fi Soweid RA , Eissenberg T . Stan-dardizing questionnaire items for the assessment of water-pipe tobacco use in epidemiological studies . Public Health . 2005 ; 119 ( 5 ): 400 - 404 .


http://www.who.int/tobacco/global_interaction/tobreg/Waterpipe%20recommendation_Final.pdf



http://slati.lungusa.org/reports/Trend%20Alert_Waterpipes.pdf

http://slati.lungusa.org/reports/Trend%20Alert_Waterpipes.pdf


DOI 10.1378/chest.10-0991; Prepublished online July 29, 2010; 2011;139; 764-774Chest

Abou Jaoude, Roland Honeine and Elie A. AklDany Raad, Swarna Gaddam, Holger J. Schunemann, Jihad Irani, Philippe

Review and Meta-analysisEffects of Water-Pipe Smoking on Lung Function : A Systematic

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