Waterpipe tobacco smoking is increasing in popularity worldwide and available evidence point to its addictive and harmful potential. This study is conducted to assess nicotine exposure in daily waterpipe users smoking the waterpipe according to their usual routine. The correlation between nicotine exposure and puff topography parameters has also not been explored systematically. Sixty-one waterpipe tobacco smokers (56 males; mean age ± SD, 30.9 ± 9.5 years; mean number of weekly waterpipe smoking episodes 7.8 ± 5.7) abstained from smoking for at least 24 hrs, and then smoked tobacco from a waterpipe ad libitum in a laboratory setting. During the session puff topography parameters were monitored continuously, and pre- and post-smoking expired-air CO was measured. Before and after smoking, venous blood was sampled for the assessment of plasma nicotine using Gas Chromatography-Mass Spectrometry. Average pre- and post-smoking expired-air CO was 4 ± 1.7 and 35.5 ± 32.7 ppm, respectively (i.e., a CO boost of 31.5 ppm, p < .01). Mean plasma nicotine concentration increased from 3.07±3.05 ng/ml pre-smoking to 15.7 ± 8.7 ng/ml post-smoking (p < .01). Plasma nicotine boost was correlated with total session time (Pearson correlation coefficient r = .31, p = .04), cumulative puff duration (r = .37, p = .01), mean puff duration (r = .34, p = .02), and total smoke inhaled in the session (r = .34, p = .02. These data show considerable nicotine exposure in daily waterpipe smokers, and that nicotine exposure is a function of waterpipe smoking patterns.

The FCTC provided a framework that applies to all forms of tobacco and this encouraged some parties to adopt control measures against NCTP and to incorporate them into their national tobacco control plans. Although a number of countries have adopted measures specifically targeted towards smokeless and waterpipe tobacco, greater global progress is needed. The strongest achievements have been in protection from exposure to tobacco smoke; controlling advertising, promotion and sponsorship; controlling sales to and by minors; education, communication and public awareness; and packaging and labelling of NCTP. Countries which adopted broad definitions of tobacco products have demonstrated encouraging trends in curbing their use. Future work should address the deep-rooted social acceptance of NCTP, the laxity in their control, their exclusion from regulations in some countries and the failure to subject them to increased taxation. Control measures should also specifically target the initiation risk to youth and adolescents and all factors that contribute to that such as banning flavourings and promotions through social media. Stronger global surveillance of NCTP use, tracking of policy implementation and evaluation of policy impact will provide important evidence to assist parties in fully implementing the FCTC to control their use.

Background In the past decade, waterpipe smoking—also known as hookah, shisha, narghileh—has increased among youth. The scarcity of rigorous studies linking waterpipe smoking to smoking-related diseases has hindered policy and regulatory efforts to confront the waterpipe epidemic. This study compares systemic carcinogen exposure between independent groups of exclusive waterpipe smokers, cigarette smokers and nonsmokers. Methods This study was conducted at the Syrian Center for Tobacco Studies (SCTS) in Aleppo, Syria, between 2010 and 2011. First morning urinary samples were collected from three groups of subjects; exclusive daily waterpipe smokers (n=24), exclusive daily cigarette smokers (n=23), and non-smokers (n=28). These samples were analysed for carcinogenic tobacco-specific nitrosamines 4-(methylnitrosamino)-1-(3-pyridyl)-1-butanol (NNAL) using liquid chromatography—tandem mass spectrometry (LC-MS/MS). Results Our results show that waterpipe smokers are exposed to about 5–10 times greater NNAL than nonsmokers. Mean (95% CI) free and total NNAL was 0.7 (0.3 to 1. 4) and 3.9 (1.6 to 9.5) pg/mL urine for nonsmokers, 8.4 (4.8 to 14.8) and 33.0 (21.6 to 50.6) pg/mL urine for waterpipe smokers, and 10.7 (5.0 to 22.6) and 46.8 (27.6 to 79.3) pg/mL urine for cigarette smokers (p<0.001 for all comparisons). Daily waterpipe smokers were less exposed to NNAL than daily cigarette smokers, although the difference did not reach statistical significance for all measurements. Conclusions These results provide the clearest indication to date about systemic exposure to harmful carcinogens associated with long-term waterpipe smoking. Such evidence can support policy and regulatory efforts designed to confront the emerging global waterpipe epidemic, as well as drive interventions aimed at increasing the public awareness about the cancer risk associated with waterpipe smoking.

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