Hookah Smoking, Hot Tea Drinking, Contaminated Water and Oesophageal Cancer // 09 March 2010

Correspondence relating to: Islami F, Kamangar F, Nasrollahzadeh D, Møller H, Boffetta P, Malekzadeh R. Oesophageal cancer in Golestan Province, a high-incidence area in northern Iran - A review. Eur J Cancer, Volume 45, Issue 18, December 2009, Pages 3156-3165.

Correspondence

SIR - Together with a fair number of other factors, Islami and his team had found a possible association (in intensity but not in duration) between hookah (called narghile and shisha elsewhere in the world) tobacco smoking and oesophageal cancer (OC) risk. To make the picture clearer, opium smoking in hookah, as a possible confounder, was discarded [1-3]. More recently, they found an unexpected association between hot tea drinking and OC [4].

In their last review published in the European Journal of Cancer, the researchers wisely warn against other confounding factors to be found in the local environment itself. They mention, among others, polycyclic aromatic hydrocarbons, N-nitroso compounds and drinking water contaminants [1]. Broadly taken, their interesting findings and the accompanying relevant discussion, bring out 3 main facts as far as research on hookah smoking is concerned, in the light of the world scientific literature on this issue.

Firstly, (contaminated) water might be a confounder because the smoke produced by a hookah is water-filtered in its half-filled vessel. This peculiar phenomenon is also exemplified by Egyptian scientists who showed that the filtration of lead in a local water pipe (goza) was superior to that of the cigarette filter [5]. They noted that this effect strikingly decreased between one smoking session and the next. Other Egyptian researchers concentrated on this fact and speculated that it could be due to a lack of hygiene as not all smokers would change the water after each session [6]. The main point here is that water and smoke in a hookah interact to varying degrees. It is also noteworthy that the tobacco (tumbeki) itself, which is packed in the bowl at the top of the Iranian water pipe, is previously soaked, for hours  on end sometimes.

Secondly, it should be stressed that hot tea drinking, found to be associated with OC [4], is an important component of the daily traditional hookah parties in Iran. Thirdly, if the association of tobacco with OC in the studied area (Golestan) is not as strong as that seen in Western countries [1], then it is even more counterintuitive in view of the elevated amounts of tobacco (dozens of grams vs. 1 g for a cigarette) smoked in a hookah [7].

As a consequence, the Iranian researchers are invited to amend their questionnaire accordingly, particularly within the framework for the mentioned ongoing cohort study [1].

Kamal Chaouachi

Chargé de cours à la Faculté de médecine de l'Université de Paris Sud (DIU de tabacologie), University Paris XI, Paris, France.

Correspondence to:

Dr. Kamal Chaouachi

Email: kamcha@gmail.com

References:

[1] Islami F, Kamangar F, Nasrollahzadeh D, Møller H, Boffetta P, Malekzadeh R. Oesophageal cancer in Golestan Province, a high-incidence area in northern Iran - A review. Eur J Cancer. 2009 Oct 1. [Epub ahead of print] http://www.ncbi.nlm.nih.gov/pubmed/19800783

[2] Chaouachi K. Hookah, opium and tobacco smoking in relation to oesophageal squamous cell carcinoma. Br J Cancer. 2009 Mar 24;100(6):1015

http://www.nature.com/bjc/journal/vaop/ncurrent/abs/6604958a.html

[3] Malekzadeh R, Nasrollahzadeh D, Kamangar F. Reply: Hookah, opium, and tobacco smoking in relation to ESCC. Br J Cancer. 2009; 100 (6): 1016.

[4] Islami F, Pourshams A, Nasrollahzadeh D, Kamangar F, Fahimi S, Shakeri R, Abedi-Ardekani B, Merat S, Vahedi H, Semnani S, Abnet CC, Brennan P, Møller H, Saidi F, Dawsey SM, Malekzadeh R, Boffetta P. Tea drinking habits and oesophageal cancer in a high risk area  in northern Iran: population based case-control study. BMJ. 2009 Mar 26;338:b929.

[5] Salem ES, Mesrega SM, Shallouf MA, Nosir MI. Determination of lead levels in cigarette and goza smoking components with a special reference to its blood values in human smokers. The Egyptian journal of chest diseases and tuberculosis 1990: 37(2).

[6] WHO-EMRO (World Health Organisation - Eastern Mediterranean Regional Office) and ESPRI (Egyptian Smoking Prevention Research Institute) 2007. Shisha Hazards Profile "Tobacco Use in Shisha - Studies on Water-pipe Smoking in Egypt". Cairo. ISBN: 978-92-9021-569-1. 84 pages. Prepared by senior editors: Mostafa K. Mohamed, Christopher A. Loffredo, Ebenezer Israel et al.

[7] Sajid KM, Chaouachi K, Mahmood R. Hookah smoking and cancer. Carcinoembryonic Antigen (CEA) levels in exclusive/ever hookah smokers, Harm Reduction Journal 2008 24 May; 5 (19) http://www.harmreductionjournal.com/content/pdf/1477-7517-5-19.pdf