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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services can be found online on the World Wide Web at: The online version of this article, along with updated information and
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written permission of the copyright holder.this article or PDF may be reproduced or distributed without the priorDundee Road, Northbrook, IL 60062. All rights reserved. No part of Copyright2011by the American College of Chest Physicians, 3300Physicians. It has been published monthly since 1935.
is the official journal of the American College of ChestChest
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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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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.
© 2011 American College of Chest Physicians at Suny at Stony Brook on April 8, 2011chestjournal.chestpubs.orgDownloaded from
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.
© 2011 American College of Chest Physicians at Suny at Stony Brook on April 8, 2011chestjournal.chestpubs.orgDownloaded from
www.chestpubs.org CHEST / 139 / 4 / APRIL, 2011 767
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)
© 2011 American College of Chest Physicians at Suny at Stony Brook on April 8, 2011chestjournal.chestpubs.orgDownloaded from
768 Original Research
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)
© 2011 American College of Chest Physicians at Suny at Stony Brook on April 8, 2011chestjournal.chestpubs.orgDownloaded from
www.chestpubs.org CHEST / 139 / 4 / APRIL, 2011 769
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)
© 2011 American College of Chest Physicians at Suny at Stony Brook on April 8, 2011chestjournal.chestpubs.orgDownloaded from
770 Original Research
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
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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.
© 2011 American College of Chest Physicians at Suny at Stony Brook on April 8, 2011chestjournal.chestpubs.orgDownloaded from
772 Original Research
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
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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.
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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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774 Original Research
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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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