ADHA Access March 2012 : Page 9

 Health Hazards of Hookah and Bidi Cigarettes By Toni-Ann Restivo Introduction he original version of this article contains an informative review of the history of hookah and bidi cigarettes. It is omit-ted here for space but will be available online at www.adha. org/publications/strive/strive.htm T Hookah Components The hookah incorporates a bowl (base), body, head and hose with a mouthpiece. The bowl is ¿ lled with water and supports the freestanding unit as it is smoked. The head holds the tobacco. The body connects the head to the bowl, dipping into the water about one-fourth of the way, allowing bubbles to emerge as the hookah is smoked. About three fourths of the way down the body, a metal slot allows the hose to be inserted. At the other end of the hose, the mouth-piece allows the user to inhale the smoke being generated within the hookah. Within the head, the dish used to hold the tobacco is cov-ered with punctured aluminum foil or a metal screen. The to-bacco itself “due to its high moisture content, does not burn in the self-sustaining manner that characterizes [a] cigarette. To sustain the smoke generation process, a continuous heat source—normally burning charcoal—is placed on top of the tobacco at the start of a use session” 1 and remains undis-turbed throughout the smoking session. A typical “hookah smoking session lasts 45 minutes to one hour, but may last up to several hours” during which smoke will become gener-ated from the head, down into the body through the water, then back up through the hose to terminate at the mouth-piece where the smoker inhales the smoke. 2 Hookah tobacco includes a wide variety of sweetening agents in addition to tobacco. The most important constitu-ent is called ma’assel, which is “a heavily sweetened and À avored tobacco mixture that lists µ molasses’ as an ingre-dient. When ma’assel is smoked, it releases an aroma of caramelizing sugar.” 1 Examples of other types of sweetening agents that are commonly used are “honey, dried fruits, or even glycerin.” 2 These sweetening agents are responsible for providing the smoker with the pleasurable aromas and À avors associated with hookah. Hookah can be smoked by one person, but it is generally is shared in groups, especially when at a hookah café or lounge, with all users sharing the same hose and mouthpiece but employing individual mouth-piece protectors to prevent cross contamination. of tobacco.” 3 The rationale for this theory is that the water component of the bowl ¿ lters out the harmful toxins found within the tobacco before the user inhales it. However, through recent research, it has been found that “this form of smoking may be just as addictive as and perhaps even more harmful than cigarette smoking.” 3 Because of the way a hoo-kah is smoked, it may become more potent and potentially more harmful than smoking a single cigarette. For example, a single cigarette lasts only a few minutes, while smoking a single hookah can last up to one hour. This increases the exposure time to harmful toxins found within the smoke. Also, hookah uses a constant source of heat that exposes “smokers and those in their company [to] inhale charcoal combustion emissions in addition to the constituents released from the tobacco mixture.” 1 Two important charcoal emissions, carbon monoxide (CO) and polyaromatic hydrocarbons (PAH) have been found in hookah smoke. Both of these compounds are toxins and have carcinogenic properties. Carcinogens cause cancer by interfering with the cell cycle, which leads to uncontrolled cell proliferation. CO competes with oxygen when binding to cells, and has a higher af ¿ nity than oxygen. As the amount of CO bound to cells increases, the amount of oxygen decreas-es. Since the body cannot use CO to produce cellular energy, the cell starves, potentially to death. PAHs readily form isomers, meaning that they can easily change their chemical structure. This characteristic makes them potent carcinogens as they bind to DNA side chains altering DNA repair, replica-tion and growth. 1 6SHFL¿F+HDOWK&RQFHUQVIRU+RRNDK Smoking hookah increases risk for several types of cancers—including lung, bladder and oral cancer—and is a Harmful Chemicals Found in Hookah “Waterpipe smoking is widely perceived to be less harm-ful and addictive than smoking cigarettes or other forms Two important charcoal emissions, carbon monoxide and polyaromatic hydrocarbons have been found in hookah smoke. Both of these compounds are toxins and have carcinogenic properties. access MAR 2012 9

Strive

Toni-Ann Restivo

Health Hazards of Hookah and Bidi Cigarettes Introduction The original version of this article contains an informative review of the history of hookah and bidi cigarettes. It is omitted here for space but will be available online at www.adha. org/publications/strive/strive.htm Hookah Components The hookah incorporates a bowl (base), body, head and hose with a mouthpiece. The bowl is filled with water and supports the freestanding unit as it is smoked. The head holds the tobacco. The body connects the head to the bowl, dipping into the water about one-fourth of the way, allowing bubbles to emerge as the hookah is smoked. About three fourths of the way down the body, a metal slot allows the hose to be inserted. At the other end of the hose, the mouthpiece allows the user to inhale the smoke being generated within the hookah. Within the head, the dish used to hold the tobacco is covered with punctured aluminum foil or a metal screen. The tobacco itself “due to its high moisture content, does not burn in the self-sustaining manner that characterizes [a] cigarette.To sustain the smoke generation process, a continuous heat source—normally burning charcoal—is placed on top of the tobacco at the start of a use session”1 and remains undisturbed throughout the smoking session. A typical “hookah smoking session lasts 45 minutes to one hour, but may last up to several hours” during which smoke will become generated from the head, down into the body through the water, then back up through the hose to terminate at the mouthpiece where the smoker inhales the smoke.2 Hookah tobacco includes a wide variety of sweetening agents in addition to tobacco. The most important constituent is called ma’assel, which is “a heavily sweetened and flavored tobacco mixture that lists hmolasses’ as an ingredient.When ma’assel is smoked, it releases an aroma of caramelizing sugar.”1 Examples of other types of sweetening agents that are commonly used are “honey, dried fruits, or even glycerin.”2 These sweetening agents are responsible for providing the smoker with the pleasurable aromas and flavors associated with hookah. Hookah can be smoked by one person, but it is generally is shared in groups, especially when at a hookah café or lounge, with all users sharing the same hose and mouthpiece but employing individual mouthpiece protectors to prevent cross contamination. Harmful Chemicals Found in Hookah “Waterpipe smoking is widely perceived to be less harmful and addictive than smoking cigarettes or other forms of tobacco.”3 The rationale for this theory is that the water component of the bowl filters out the harmful toxins found within the tobacco before the user inhales it. However, through recent research, it has been found that “this form of smoking may be just as addictive as and perhaps even more harmful than cigarette smoking.”3 Because of the way a hookah is smoked, it may become more potent and potentially more harmful than smoking a single cigarette. For example, a single cigarette lasts only a few minutes, while smoking a single hookah can last up to one hour. This increases the exposure time to harmful toxins found within the smoke.Also, hookah uses a constant source of heat that exposes “smokers and those in their company [to] inhale charcoal combustion emissions in addition to the constituents released from the tobacco mixture.”1 Two important charcoal emissions, carbon monoxide (CO) and polyaromatic hydrocarbons (PAH) have been found in hookah smoke. Both of these compounds are toxins and have carcinogenic properties. Carcinogens cause cancer by interfering with the cell cycle, which leads to uncontrolled cell proliferation. CO competes with oxygen when binding to cells, and has a higher affinity than oxygen. As the amount of CO bound to cells increases, the amount of oxygen decreases.Since the body cannot use CO to produce cellular energy, the cell starves, potentially to death. PAHs readily form isomers, meaning that they can easily change their chemical structure. This characteristic makes them potent carcinogens as they bind to DNA side chains altering DNA repair, replication and growth.1 Specific health concerns for hookah Smoking hookah increases risk for several types of cancers—including lung, bladder and oral cancer—and is a Risk factor for periodontal disease. Because hookah smoke is inhaled, the lung cells are directly exposed to carcinogens, where they bind to DNA, thus altering normal cell functions. In addition, since the harmful components of hookah are ..ltered out of the body via the urinary system, they have been found to impinge on cells found along this system, altering their ..ltration properties. With regards to oral cancers, “irritation from exposure to tobacco juices increases the risk of developing oral cancers.. the irritation by tobacco juice products is likely to be greater among hookah smokers than among pipe or cigar smokers because hookah smoking is typically practiced (with or without inhalation) more often and for longer periods of time.”4 Smoking hookah is just as much a potential risk factor for periodontal disease as smoking conventional cigarettes. This has been demonstrated through a cross-sectional study in Saudi Arabia, where periodontal disease was measured using probing depths among 262 participants aged 17-60 years. “The prevalence of periodontal disease defined as a minimum of 10 sites with a probing depth of 5 mm was 19. 5 percent in the total population, 30 percent in water pipe smokers, 24 percent in cigarette smokers and 7 percent in non-smokers.The relative risk for periodontal disease was 5.1 and 3.8-fold higher for water-pipe and cigarette smokers respectively, compared to nonsmokers.” This study indicates that smoking of either type, whether it was hookah or cigarettes, is a potent risk factor for periodontal disease.2 Bidi Cigarette Components and Harmful Constituents “Bidi is a leaf-rolled cigarette made of coarse, uncured tobacco, tied with a string at one end.”5 Its tobacco is rolled in the leaf of a tendu tree, and just like hookah tobacco it is available in a variety of flavors, which helps to increase its appeal. In addition, bidis are cheaper than conventional cigarettes and mimic the appearance of a marijuana cigarette, which are both believed to help increase its popularity.6 Just like hookah, “these cigarettes are perceived as a safer, more natural alternative to conventional cigarette smoking..” however, it has been determined that they are equally or more harmful than regular cigarettes.6 As seen with hookah, there are carcinogenic additives such as phenol, hydrogen cyanide, benzo(a)pyrenes, and nitrosamines that are responsible for increased cancer risk associated with consuming this product. Phenols are believed to be carcinogenic because they cause lung edema. Lung edema disrupts normal respiratory cell functioning. Edema is defined as swelling due to water retention. This occurs because phenols are alcohol compounds that, through osmosis, cause water to be retained within the lung. Hydrogen cyanide is known to inhibit cellular respiration. It is a potent toxin that inhibits the enzymes associated with the electron transport chain found within mitochondria. This blocks cellular energy from being produced, and if inhibited long enough, these cells will die due to a lack of cellular energy needed to carry out normal functions. Benzo(a) pyrenes and nitrosamines are both chemical compounds that directly bind to DNA and inhibit its replication and repair systems. They bind to the side chains of DNA and inhibit its enzymatic activity as well as cause mutations along the chain. This creates a nonfunctioning or an exaggerated function of DNA, which can lead to uncontrolled proliferation of cells, as seen in cancer.6 Harmful Effects from Smoking Bidis It has been proven that smoking bidi cigarettes leads to elevated CO levels, as well as “higher risks of hypertension, coronary heart disease, oral (specifically tongue and floor of mouth) cancer and lung cancers.”6 As seen in hookah, smoking increases exposure to CO. CO is a potent antagonist of oxygen. It readily binds to iron thus blocking oxygen from binding.. however, unlike oxygen, CO cannot be used to produce cellular energy. Over time an increase in CO causes cells to die because they are starved from cellular energy and cannot carry out normal functioning. It has been proven in a cohort study done on men using bidi cigarettes in Karunagappally, Kerala, India that “bidi smoking significantly increased oral cancer risk.”7 In addition, it has been shown “in location-specific analysis, [that] bidi smoking was significantly associated with cancer of the gum and mouth.”7 This study revealed a positive correlation between the duration and frequency of bidi use and the increased risk for oral cancers—especially of the floor of the mouth and periodontal tissue—when compared to those who never consumed this product. When considering bidi smoking as a risk factor for lung cancer, it has been suggested that people who smoke this product take deeper puffs, which increases the amount of smoke available to become absorbed by respiratory cells. Since the smoke has various carcinogenic chemicals, these chemicals interfere with the normal functioning of respiratory cells. This often leads to respiratory cell death and/or inhibition of normal cell functioning. This in turn can cause uncontrolled proliferation of respiratory cells, thus leading to lung cancer, which is commonly seen as the frequency and duration of use increases.6 Hazards Common to Both Types of Smoking Smoking either hookah or bidis is a risk factor for cardiovascular diseases, nicotine dependence, increased risk to spread communicable diseases and secondhand smoke. Smoking in general, whether using hookah or bidis, is a risk factor for cardiovascular disease.Because of the “numerous toxic substances known to cause clogged arteries” and increased concentrations of CO from smoking, both increase the chances for heart disease.4 Smoking leaves plaques and increases fat deposits along arteries and vessels, which constricts the size of the vessel, thus decreasing blood ..ow throughout the body.This increases stress on the heart to deliver the same quantity of blood via narrower vessels, which ultimately leads to hypertension. In addition, decreased oxygen ..ow back to the heart due to the narrowing of its vessels can lead to coronary heart disease, as these cells become starved for cellular energy to carry out normal functioning.4 Furthermore, as the concentration of CO in cells increases, the amount of oxygen decreases because both compete with one another.However, since CO has a stronger af..nity for cells, it binds more readily than oxygen, leading to a decrease in the amount of oxygen available for exchange via the cardiopulmonary system. This could lead to a heart attack, as heart cells are starved from oxygen and cannot produce the cellular energy needed to pump blood around the body.4 Nicotine dependence is a concern when consuming hookah or bidi cigarettes. A single hookah session lasts approximately one hour and has been found to deliver “10-50 percent more nicotine” than a single cigarette.2 In addition, smoking bidis delivers “concentrations of nicotine three times the amount found in a filtered, conventional cigarette.”6 This indicates that both can be potentially more addictive than cigarette smoking because of the alarming increase in nicotine delivered during a single session. Smoking can spread communicable diseases. This idea is especially true with hookah because it is typically smoked in groups sharing the same hose and mouthpiece. However, there also has been evidence of people sharing bidi cigarettes and thereby increasing the chances of spreading disease—tuberculosis, for example, which spreads from an infected person via aerosols created by coughing or sneezing or through direct saliva contact. Other communicable diseases that may be transmitted using both types of tobacco products in a group setting are herpes, hepatitis and other illnesses such as influenza or the common cold.4 When smoking in a public area, secondhand smoke becomes an important risk factor for disease. According to the Centers for Disease Control and Prevention, “secondhand smoke from hookahs poses a serious risk for nonsmokers, particularly because it contains smoke not only from the tobacco but also from the heat source.”4 Secondhand smoke from bidi cigarettes is equally damaging because it exposes everyone to the smoke even if they themselves are not consuming it. This allows everyone around the smoke to become Exposed to the various toxins, thereby increasing the harmful risks for nonsmokers. Conclusion Smoking hookah and bidis has been a tradition dating back to as early as 16th and 17th century India. Upon their introduction they both became popular and started to spread worldwide as a social smoking trend. Though hookah and bidis are different means of smoking, they are similar in that they are available in a variety of flavors, making them more appealing for use. In addition it has been found that both are potential risk factors for various cancers, coronary heart disease, nicotine dependence and secondhand smoke. The role of a health care provider should be to identify users of alternative smoking using a hookah or bidi cigarettes through a patient’s medical history. Due to the prevalence and increasing popularity of hookah lounges and bidi cigarettes becoming commercially available in the United States, it should be the responsibility of health care providers to evaluate patients’ medical histories and if they are smokers of either or both, to incorporate this concern into the treatment care plan. The treatment care plan should include patient education on the adverse health implications associated with consuming either tobacco product, along with tobacco cessation options. It is imperative that we as health care providers explain the various health risks associated with smoking bidis or hookah. At this time, the patient should become aware that the only way to prevent the risks imposed by either of these two products would be to avoid usage, or if using these products, to stop usage immediately to help restore normal cell function. References 1. Monzer B, Sepetdjian E, Saliba N, Shihadeh A. Charcoal emissions as a source of co and carcinogenic pah in mainstream narghile waterpipe smoke. Food and Chemical Toxicity. 2008; 46(9): 2991-5. Available at: www.sciencedirect. com. 2. Ray CS. The hookah-the Indian waterpipe. Current Science. 2009; 96(10): 1319-23. Available at: docs.google.com/viewer. 3. Harvard Medical School. The hazards of hookah. Harvard Mental Health Letter. 2008; 24(9): 1-4. Available at: ehis.ebscohost.com.central.ezproxy. cuny.edu:2048/ehost/pdfviewer/pdfviewer. 4. Centers for Disease Control and Prevention. Smoking and tobacco use: fact sheet: hookahs. 2011. Available at: www.cdc.gov/tobacco/data_statistics/ fact_sheets/tobacco_industry/hookahs/. 5. Lal P. Bidi—a short history. Current Science. 2009; 96(10): 1335-7. Available at: www.ias.ac.in/currsci/may252009/1335.pdf. 6. Malson JL, Pickworth WB. Bidis—hand-rolled, Indian cigarettes: effects on physiological, biochemical, and subjectivity measures. Pharmacol Biochem Behav. 2002; 72(1,2): 443-7. Available at: www.sciencedirect.com. 7. Jayalekshumi PA, Gangadharan P, Akiba S, et al. Oral cavity cancer risk in relation to tobacco chewing and bidi smoking among men in Karunagappally, Kerala, India: Karunagappally cohort study. Cancer Science. 2011; 102(2): 460-7. Available at: onlinelibrary.wiley.com.citytech.ezproxy.cuny. edu. Toni-Ann Restivo is currently a second-year dental hygiene student at New York City College of Technology, Brooklyn, N.Y., with an expected graduation of June 2012. She also has an associate’s and bachelor’s degree in biology, with a minor in psychology, from the College of Staten Island. The faculty mentor for this edition of Strive is Susan Davide, RDH, MS, MSEd, assistant professor, Dental Hygiene Department at NYCCT.

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