Editorial
Shishas: another way of tobacco smoking… Another source of exposure to toxic compounds
Cachimbas: otra forma de fumar tabaco… Otra fuente de exposición a compuestos tóxicos
Marcela Fu
, Ariadna Feliu, Esteve Fernández
Corresponding author
Unidad de Control del Tabaco, Centro Colaborador de la OMS para el Control del Tabaco, Institut Català d'Oncologia (ICO), L’Hospitalet de Llobregat; Grupo de Investigación en Control del Tabaco, Institut d'Investigació Biomèdica de Bellvitge (IDIBELL), L’Hospitalet de Llobregat; Facultad de Medicina y Ciencias de la Salud, Universitat de Barcelona (UB), L’Hospitalet de Llobregat; Centro de Investigación Biomédica en Red de Enfermedades Respiratorias (CIBERES), Madrid, Spain
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Grupo de Investigación en Control del Tabaco, Institut d'Investigació Biomèdica de Bellvitge (IDIBELL), L’Hospitalet de Llobregat; Facultad de Medicina y Ciencias de la Salud, Universitat de Barcelona (UB), L’Hospitalet de Llobregat; Centro de Investigación Biomédica en Red de Enfermedades Respiratorias (CIBERES), Madrid, Spain" "identificador" => "aff0005" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Cachimbas: otra forma de fumar tabaco… Otra fuente de exposición a compuestos tóxicos" ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">Waterpipes, also known as shishas, hookahs, or narghiles, are devices for the shared smoking of tobacco, herbs, or other substances impregnated with molasses, which are placed in a bowl where they are lit with small coals. The smoke passes through a vertical stem to a water container where it is cooled and humidified, before it is drawn from a distance through the mouthpiece of one or more hoses.<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">Waterpipes are mainly used with tobacco and there is a belief that they are healthier when they do not contain it. However, with the exception of nicotine, smoking waterpipes without tobacco has been shown to generate the same toxic compounds as when used with tobacco, in similar or even higher doses.<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> In addition to carbon monoxide, burning tobacco-free herbs generates carcinogenic substances such as tar, polycyclic aromatic hydrocarbons, fine particles, and aldehydes, while burning molasses generates furanic compounds, including some tumor promoters that contribute to increased metastasis in lung cancer.<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1–3</span></a> Toxic trace metals and other carcinogens have also been found in the composition of herbal products, also in excess of those found in cigarettes.<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">Waterpipes are traditionally used in the Middle East and in some African countries; however, in recent years their use has spread in Europe.<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> In Spain, there has been an increase in the prevalence of young people who have tried waterpipes at least once in a lifetime, from 6.2% in 2009 to 10.8% in 2017.<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> In the university population, 10.3% of male students and 9.9% of female students smoked them at least occasionally in 2015–2016,<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a> while in 2018–2019, these figures had risen to 22.4% and 17.4%, respectively.<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a> Sharing devices, long smoking sessions, and the false belief that they are harmless may be some of the factors that have helped increase their use among young people.</p><p id="par0020" class="elsevierStylePara elsevierViewall">The growing popularity of waterpipes raises public health concerns for a variety of reasons. First, although the mouthpieces, and sometimes the hoses, are supplied individually, they are often shared among different users and therefore pose a risk of infectious disease transmission, particularly if they are not changed or disinfected between sessions. All other components remain unchanged and are reused for other customers. Attention has been drawn to this unhygienic use and to the potential transfer of a large amount of water droplets and saliva in exhaled smoke, particularly in the context of the current COVID-19 pandemic,<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a> and some health guidelines have been recommended, such as promoting individual use and implementing specific measures for the sanitization of reusable components, although calls have been made to discourage waterpipe use altogether.<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a></p><p id="par0025" class="elsevierStylePara elsevierViewall">Another area of concern is that tobacco smoked in waterpipes contains nicotine, which creates addiction and also favors the initiation and consolidation of tobacco use in any of its forms. Furthermore, the smoke from waterpipes accumulates wherever they are used, passively exposing workers and customers to various toxic substances emitted by burning not only tobacco, herbs and molasses, but also the coals used in the process; the latter contribute to high levels of carbon monoxide, which can even cause acute poisoning,<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a> and polycyclic aromatic hydrocarbons, some of which are carcinogenic.<a class="elsevierStyleCrossRefs" href="#bib0050"><span class="elsevierStyleSup">10,11</span></a></p><p id="par0030" class="elsevierStylePara elsevierViewall">The smoke generated by waterpipes is therefore an important source of pollution wherever they are used. Concentrations of fine particles in premises where only waterpipes are smoked are higher than those found in premises where only cigarettes are smoked,<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">12</span></a> even when they are used without tobacco.<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> In Spain, the extent of this exposure in a metropolitan city such as Barcelona has been investigated by quantifying air nicotine (a specific marker of tobacco exposure) and fine particles (PM<span class="elsevierStyleInf">2.5</span>) in 20 premises where waterpipes were used.<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">13</span></a> The median nicotine concentration measured in 30 min was 1.15 μg/m<span class="elsevierStyleSup">3</span>, with a maximum level of 8.16 μg/m<span class="elsevierStyleSup">3</span>, while the median concentration of PM<span class="elsevierStyleInf">2.5</span> was 230.50 μg/m<span class="elsevierStyleSup">3</span>, with a maximum level of 1758 μg/m<span class="elsevierStyleSup">3</span>. These concentrations were significantly higher than those recorded in smoke-free sites: only 0.03 μg/m<span class="elsevierStyleSup">3</span> and 10.00 μg/m<span class="elsevierStyleSup">3</span>, respectively. Concentrations of these markers were significantly higher in premises bigger than 100 m<span class="elsevierStyleSup">2</span>, located in tourist areas, in which more than 15 waterpipes were in use, with more than 8 waterpipes per 100 m<span class="elsevierStyleSup">2</span> and up to 2 users per pipe. These results are significant, because the tobacco legislation in force in Spain, as in other countries, does not explicitly mention tobacco smoked in waterpipes, highlighting the legal vacuum in these premises, where not only waterpipes are used with tobacco, but conventional cigarette consumption is also tolerated, as observed in the same study.<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">13</span></a> It should be noted that, as with other forms of tobacco smoking, both the use of waterpipes and passive exposure to their toxic compounds are associated with an increased risk and worsening of various health conditions, such as cardiovascular disease, including stroke and acute myocardial infarction; respiratory diseases, such as asthma and lung disease; and various types of cancer, including lung cancer.<a class="elsevierStyleCrossRefs" href="#bib0070"><span class="elsevierStyleSup">14,15</span></a> For all the reasons stated above, and following the recommendations of the World Health Organization,<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">11</span></a> we call for the regulation of the use of waterpipes in public spaces, with and without tobacco, deterrents to their use in both closed and open premises, and inspections to control compliance with smoking laws. We would also urge restrictions in advertising, the application of fiscal measures to reduce its demand, particularly among young people, and the inclusion of this way of smoking in educational and preventive programs addressed to adolescents.</p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Funding</span><p id="par0035" class="elsevierStylePara elsevierViewall">The IDIBELL Tobacco Control Research Group receives funding from the <span class="elsevierStyleGrantSponsor" id="gs0005">Department of Universities and Research of the Generalitat de Catalunya</span> (<span class="elsevierStyleGrantNumber" refid="gs0005">2017SGR319</span>).</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Conflict of interests</span><p id="par0040" class="elsevierStylePara elsevierViewall">None.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:3 [ 0 => array:2 [ "identificador" => "sec0005" "titulo" => "Funding" ] 1 => array:2 [ "identificador" => "sec0010" "titulo" => "Conflict of interests" ] 2 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: Fu M, Feliu A, Fernández E. Cachimbas: otra forma de fumar tabaco... Otra fuente de exposición a compuestos tóxicos. Arch Bronconeumol. 2021;57:449–450.</p>" ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:15 [ 0 => array:3 [ "identificador" => "bib0005" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Toxicant content, physical properties and biological activity of waterpipe tobacco smoke and its tobacco-free alternatives" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:6 [ 0 => "A. Shihadeh" 1 => "J. Schubert" 2 => "J. Klaiany" 3 => "M. el Sabban" 4 => "A. Luch" 5 => "N.A. Saliba" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1136/tobaccocontrol-2014-051907" "Revista" => array:6 [ "tituloSerie" => "Tob Control." 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| Year/Month | Html | Total | |
|---|---|---|---|
| 2024 November | 10 | 3 | 13 |
| 2024 October | 50 | 26 | 76 |
| 2024 September | 61 | 17 | 78 |
| 2024 August | 68 | 35 | 103 |
| 2024 July | 53 | 21 | 74 |
| 2024 June | 53 | 30 | 83 |
| 2024 May | 85 | 22 | 107 |
| 2024 April | 35 | 19 | 54 |
| 2024 March | 41 | 18 | 59 |
| 2024 February | 30 | 30 | 60 |
| 2024 January | 28 | 28 | 56 |
| 2023 December | 20 | 22 | 42 |
| 2023 November | 42 | 31 | 73 |
| 2023 October | 30 | 35 | 65 |
| 2023 September | 31 | 28 | 59 |
| 2023 August | 37 | 31 | 68 |
| 2023 July | 34 | 24 | 58 |
| 2023 June | 28 | 21 | 49 |
| 2023 May | 40 | 29 | 69 |
| 2023 April | 39 | 26 | 65 |
| 2023 March | 41 | 46 | 87 |
| 2023 February | 46 | 28 | 74 |
| 2023 January | 38 | 43 | 81 |
| 2022 December | 87 | 36 | 123 |
| 2022 November | 90 | 29 | 119 |
| 2022 October | 78 | 39 | 117 |
| 2022 September | 63 | 48 | 111 |
| 2022 August | 88 | 33 | 121 |
| 2022 July | 91 | 51 | 142 |
| 2022 June | 39 | 30 | 69 |
| 2022 May | 41 | 27 | 68 |
| 2022 April | 61 | 42 | 103 |
| 2022 March | 51 | 43 | 94 |
| 2022 February | 17 | 21 | 38 |
| 2022 January | 1 | 0 | 1 |
| 2021 July | 2 | 0 | 2 |
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