Water Pipe (Hookah) Smoking and Cardiovascular Disease Risk: A Scientific Statement From the American Heart Association

Abstract

Tobacco smoking with a water pipe or hookah is increasing globally. There are millions of water pipe tobacco smokers worldwide, and in the United States, water pipe use is more common among youth and young adults than among adults. The spread of water pipe tobacco smoking has been abetted by the marketing of flavored tobacco, a social media environment that promotes water pipe smoking, and misperceptions about the addictive potential and potential adverse health effects of this form of tobacco use. There is growing evidence that water pipe tobacco smoking affects heart rate, blood pressure regulation, baroreflex sensitivity, tissue oxygenation, and vascular function over the short term. Long-term water pipe use is associated with increased risk of coronary artery disease. Several harmful or potentially harmful substances present in cigarette smoke are also present in water pipe smoke, often at levels exceeding those found in cigarette smoke. Water pipe tobacco smokers have a higher risk of initiation of cigarette smoking than never smokers. Future studies that focus on the long-term adverse health effects of intermittent water pipe tobacco use are critical to strengthen the evidence base and to inform the regulation of water pipe products and use. The objectives of this statement are to describe the design and operation of water pipes and their use patterns, to identify harmful and potentially harmful constituents in water pipe smoke, to document the cardiovascular risks of water pipe use, to review current approaches to water pipe smoking cessation, and to offer guidance to healthcare providers for the identification and treatment of individuals who smoke tobacco using water pipes.

Waterpipe Tobacco Smoke Inhalation Triggers Thrombogenicity, Cardiac Inflammation and Oxidative Stress in Mice: Effects of Flavouring

“…Studies assessing the similarity between cigarette smoking (CS) and WPS indicated that one daily session of WPS equates smoking of 10 cigarettes per day [3]. Moreover, it has been reported that the adverse pulmonary and systemic effects of WPS are comparable or even more marked than those of CS [4][5][6]. Several factors have been quoted to explain the significant increase in WPS use, including the misperception that it is less addictive and less harmful than CS.…”

“…In fact, several WPS users indicated that one of the reasons for their preference of WPS over CS is that they are confident of their capacity to abandon WPS when they want and that the water filters out the toxins [7,8]. Moreover, it has been reported that the use of flavoured fruit scent waterpipe tobacco to override the formerly intolerable aroma has increased its attractiveness to first-time users, particularly teenagers [6,9,10]. In fact, youths cite the pleasant taste and smell of WPS to explain the reasons for their use of WPS [6,9,10].…”

“…Moreover, it has been reported that the use of flavoured fruit scent waterpipe tobacco to override the formerly intolerable aroma has increased its attractiveness to first-time users, particularly teenagers [6,9,10]. In fact, youths cite the pleasant taste and smell of WPS to explain the reasons for their use of WPS [6,9,10]. However, little is known about the health effects of the flavouring used in WPS.…”

“…Moreover, previous human and animal studies have reported that exposure to flavoured WPS causes pulmonary inflammation, oxidative stress and alterations in lung function and morphology [12][13][14][15][16]. With respect to the cardiovascular effects of WPS, clinical studies have demonstrated that short-term WPS affects the heart rate, blood pressure, tissue oxygenation and vascular function and that the long-term use of WPS increases the risk of coronary artery disease [6,17]. We have reported experimental evidence in mice that WPS inhalation causes cardiovascular oxidative stress, inflammation and thrombotic disorders in mice [13,18].…”

Building the evidence base for waterpipe regulation and policy

“…3 The American Heart Association recently stated that waterpipe smoke delivers known tobacco toxicants and carcinogens and that waterpipe smoking is associated with many of the same risks as cigarettes smoking, such as lung cancer, and respiratory and cardiovascular diseases. 4 The spread of waterpipe smoking is also perpetuated by the lag in policy and regulatory response to address it. 5 6 This is not unexpected given its special configuration and characteristics, which influence the applicability of known effective tobacco control policies to this emerging tobacco product.…”