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Hookah Smoking

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Rashid Gatrad, consultant paediatrician1, Adam Gatrad, gap year student2, Aziz Sheikh, professor of primary care research and development3

1 Manor Hospital, Walsall, 2 University of Central England, 3 Allergy and Respiratory Research Group, Division of Community Health Sciences, University of Edinburgh. Correspondence to: A Sheikh

A hookah—also known as hubbly bubbly, shisha, or narghile—is a glass based waterpipe used for smoking. It operates by water filtration and indirect heat. Tobacco or molasses are placed in the bowl at the top of the apparatus, which is connected to the water filled base by a pipe. This bowl is then covered with perforated material, such as kitchen foil. Burning charcoal is then placed on top of the foil. During inhalation the smoke from the charcoal is pulled through the tobacco down the pipe and towards the water. After bubbling through the water, the cooled smoke surfaces and is drawn through the hose and inhaled. Some hookahs have a “choke” to control the amount of smoke inhaled. Electric burners are also available, which offer a quicker smoke than the original charcoal burners.

How common is waterpipe smoking?

Around 100 million people use a hookah daily worldwide.1 Some of these smokers are children—a study in the central region of Israel among predominantly Jewish secondary school children found that 41% had or were smoking tobacco through a hookah.2 Similarly, a US study of Arab American adolescents found that 27% had experimented with a hookah.3

Introduction of the flavoured and aromatic tobacco has helped broaden the appeal of hookahs, both in their traditional homelands and in Western Europe. In Egypt, for example, younger adults prefer fruit flavoured tobacco, whereas older people tend to prefer smoking molasses—thick treacle-like syrups that burn like tobacco leaf products but are nicotine free.

Although the hookah is commonly used for smoking herbal fruits after meals, it has recently become increasingly used for smoking tobacco, massel (aromatic tobacco), cannabis and bango (an intoxicating plant leaf).

Social activity

The hookah is commonly shared among family members including children, friends, and guests. Hookah establishments are also increasingly found around university campuses, where multiple hose waterpipes are used for group smoking. Recent work indicates that relative to cigarette smoking, tobacco used in a waterpipe is characterised by more intermittent use, greater social acceptability, increased use among women, and a lower interest in quitting, probably because people are less aware of its addictive properties.4 Family attitudes towards children smoking tobacco in waterpipes are reported to be far more permissive than attitudes to cigarette smoking.5 Our observations among the children of friends, relatives, and acquaintances confirm this.

UK experience

Rising numbers of children in the UK are being exposed to and experimenting with smoking hookah products. Although accurate data are lacking, children as young as 10 years old are known to smoke fruit flavoured aromatic tobacco in areas with large minority ethnic communities such as Leicester and London.

Hookahs are relatively commonplace in Middle Eastern restaurants. A session of smoking typically costs £5 to £15. For those wanting to smoke at home, a hookah costs from £30 to £300. Many are, however, brought over more cheaply from the Middle East after business or holiday travel.

Not all tobacco packaging exhibits a warning on the effects of tobacco or the content of nicotine. And it is relatively easy for children to buy tobacco for use in hookahs without many questions being asked.

Health risks

Little is known about the pharmacological effects and dependency associated with smoking tobacco in a hookah. The nicotine content in hookah tobacco seems to be the same as in cigarettes.6 Hookah smoking carries a greater risk of carbon monoxide poisoning than cigarette smoking,7 particularly if smaller hookah pipes and “quick lighting” commercial charcoal are used.8

There is also some evidence that hookah smoking causes chromosomal damage.9 The concentration of cancer causing additive substances may be equivalent to that in cigarettes, but hookah smokers are additionally exposed to the carcinogenic effect of hydrocarbons and heavy metals in the charcoal. Gum disease has been reported to be five times more common in hookah smokers than in cigarette smokers.10 Shared smoking also carries a small but important risk of transmitting infectious diseases directly into the respiratory tract.

Implications of UK Health Act

When used for smoking tobacco, the hookah is included in the legislation that came into force in England in July 2007 banning smoking in public places.11 We believe that including the hookah in the legislation is appropriate since the exposure of non-smokers to tobacco fumes is considerably higher than for cigarette smoking because of the large plume of smoke that the hookah generates. It remains to be seen what effect this legislation will have on smoking non-tobacco containing products that still generate a large amount of smoke.

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Stop Smoking, Cut Cataract Risk

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Published: Jan 5, 2014

By Crystal Phend, Senior Staff Writer, MedPage Today

The cataract risk associated with smoking slowly fell after ceasing tobacco use, although not to the level of a never-smoker, a Swedish population-based study showed.

Smoking more than 15 cigarettes per day was associated with 42% higher likelihood of a cataract surgery during 12 years of follow-up, Birgitta Ejdervik Lindblad, MD, PhD, of Örebro University Hospital in Örebro, Sweden, and colleagues found.

After having quit for 20 years, that risk had declined to a relative 21% above that of never-smokers, the researchers reported online in JAMA Ophthalmology.

The risk declined significantly with time (P<0.001), but “the higher the intensity of smoking, the longer it takes for the increased risk to decline,” the researchers noted.

Even lighter smokers with a fewer-than-15-a-day habit remained at significant risk 2 decades after quitting (rate ratio 1.13, 95% CI 1.04-1.24).

“These findings emphasize the importance of early smoking cessation and preferably the avoidance of smoking,” Linblad’s group concluded.

Plenty of prior studies have shown cataract and other ocular risks from smoking, so “eye care professionals should encourage people to stop smoking,” too, they recommended.

The presumed mechanism for this risk is that “smoking increases the oxidative stress in the lens by generating free radicals and reduces the plasma concentration of several antioxidants, such as ascorbic acid,” Lindblad and colleagues explained.

“Cigarette smoke also contains toxic metal ions, and cadmium can accumulate in cataractous lenses of smokers,” they added. “Cadmium may affect antioxidative lens enzymes such as superoxide dismutase and glutathione peroxidase, thereby weakening the defense against oxidative damage and hastening cataract development.”

Their analysis included 44,371 men in the Cohort of Swedish Men study ages 45 to 79 years, among whom 25% reported smoking and 39% had been smokers, based on questionnaire responses regarding smoking habits and lifestyle factors.

During 12 years of follow-up via the Swedish National Day-Surgery Register, and local registers of cataract extraction in the study area, an age-adjusted 13% had cataract extractions.

Limitations of the study included possible misclassification of self-reported smoking history, no assessment or control for sunlight or UV exposure, and lack of data on subtype of cataracts, although all were severe enough to cause visual impairment requiring lens extraction, “and therefore having the greatest clinical and public health importance.”

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Bystander CPR Better When More People Help

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Bystander CPR Better When More People Help

By Cole Petrochko, Staff Writer, MedPage Today

Reviewed by Robert Jasmer, MD; Associate Clinical Professor of Medicine, University of California, San Francisco and Dorothy Caputo, MA, BSN, RN, Nurse Planner

Action Points

  • Patients entering cardiac arrest were more likely to receive good-quality bystander-initiated cardiopulmonary resuscitation (CPR) if multiple people assisted, researchers found.
  • Note that neurologically favorable survival 1 year after the event did not differ significantly between those who received good-quality versus poor-quality resuscitation.

Cardiac arrest victims were more likely to receive good-quality bystander-initiated cardiopulmonary resuscitation (CPR) if multiple people assisted, researchers found.

Among cases of out-of-hospital cardiac arrest, CPR quality was associated with multiple rescuers initiating bystander CPR (OR 2.8, 95% CI 1.5-5.6), being in a central or urban setting (OR 2.1, 95% CI 1.3-3.3), and receipt of bystander-initiated CPR (OR 2.7, 95% CI 1.1-7.3), as well as longer duration of resuscitation (OR 1.1, 95% CI 1.0-1.1), according to Hideo Inaba, MD, of the Kanazawa University Graduate School of Medicine in Japan, and colleagues.

Good-quality bystander CPR was less commonly performed by a family member (P=0.0001), by older bystanders (P=0.0005), and in home environments (P<0.0001), they wrote online in the journalResuscitation.

However, neurologically favorable survival 1 year after the event did not differ significantly between those who received good-quality versus poor-quality resuscitation (2.7% versus 0%, P=0.14).

Experts in the field of emergency medicine have noted that the key to survival and positive neurological outcomes for those experiencing an out-of-hospital cardiac arrest is the initiation of bystander CPR. This CPR should be performed with chest compressions onlywithout mouth-to-mouth resuscitation.

However, the authors noted that survival among patients with out-of-hospital cardiac arrest remains low.

The Japanese study followed self-reported observational data from emergency medical technicians (EMTs) in Ishikawa prefecture who arrived on the scene at 553 out-of-hospital cardiac arrests. The EMTs requested that the bystander administering CPR continue resuscitating the patient after arrival and evaluated whether bystander-initiated CPR was of good or poor quality based on:

  • Appropriate hand positions or finger positions for infants
  • Compression rate of at least 100 per minute
  • Compression depth of at least 2 inches or at least one third of the anterior-posterior diameter of the chest

The authors also gathered information on the region of the arrest, location, the patient’s age and sex, witnesses to the event, etiology of the arrest, whether or not CPR was initiated by a bystander or with the instruction of emergency medical services dispatch, type of CPR initiated, training experience of the bystander, initial cardiac rhythm, estimated time of collapse, time-points initiation of CPR bystanders and EMTs, time from call to EMT to arrival, sustained return of spontaneous circulation, 1-month survival, 1-year survival, and 1-year favorable survival with neurologically favorable outcomes.

Neurologically favorable outcomes were categorized as scores of one or two on the Glasgow-Pittsburgh cerebral performance categories test.

Time to calling emergency services from arrest did not differ between groups, though time to arrest or recognition of arrest to initiation of CPR was significantly shorter among those who provided good-quality CPR (median 3 minutes versus 4 minutes, P=0.0052).

The authors noted that their findings related to setting of the arrest and related resuscitation may vary in other regions, as “previous studies from other countries suggest that regional variation in the quality of EMS systems, including differences in out-of-hospital cardiac arrest outcomes and bystander characteristics, may differ among countries,” and that one of those prior studies had findings opposite of what was found in their research. “The reasons for this difference are unclear,” they wrote.

They also noted that the study was limited by CPR quality measurement only after the arrival of EMTs and not in the time between dispatch and arrival, by lack of evaluation of bystander background or training history, by a self-reported and estimated time of arrest, and by a sample size not large enough to detect significance in differences in neurological outcomes.

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Passive and active smoking are both risk factors early breast cancer

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Results of studies “with thorough passive smoking exposure assessment” indicate that passive smoking raises the risk of breast cancer, especially premenopausal disease, to a similar degree as active smoking.

Dr. Kenneth C. Johnson, of the Public Health Agency of Canada, Ottawa, Ontario, examined the association between breast cancer risk and passive and active smoking in a meta-analysis of 19 published studies that met basic quality criteria. Results are published in the November issue of the International Journal of Cancer.

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New Colon Cancer Screening Option Shows Advantages

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By Neil Osterweil , MedPage Today Staff Writer. Reviewed by Robert Jasmer, MD; Assistant Professor of Medicine, University of California, San Francisco

Review: OKAYAMA, Japan, Aug. 23-Fecal immunochemical tests (FIT) are an improved approach to fecal occult blood tests for detecting possible colorectal cancer, according to researchers here.

Nevertheless, FIT has a relatively low sensitivity and is better at picking up some tumors than others, according to Jun Kato, M.D., of Okayama University and colleagues reported in the August issue of Gastroenterology.

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