Clinical Reviews in Allergy & Immunology

, Volume 46, Issue 1, pp 34–53

Non-Cigarette Tobacco and the Lung



Cigarette smoking is known to cause a wide range of damaging health outcomes; however, the effects of non-cigarette tobacco products are either unknown or perceived as less harmful than cigarettes. Smokeless tobacco, cigar smoking, and waterpipe smoking have increased in usage over the past few decades. Some experts believe that their use is reaching epidemic proportions. Factors such as a perception of harm reduction, targeted advertising, and unrecognized addiction may drive the increased consumption of non-cigarette tobacco products. In particular, the need for social acceptance, enjoyment of communal smoking activities, and exotic nature of waterpipe smoking fuels, in part, its popularity. The public is looking for “safer” alternatives to smoking cigarettes, and some groups advertise products such as smokeless tobacco and electronic cigarettes as the alternatives they seek. Though it is clear that cigar and waterpipe tobacco smoking are probably as dangerous to health as cigarette smoking, there is an opinion among users that the health risks are less compared to cigarette smoking. This is particularly true in younger age groups. In the cases of smokeless tobacco and electronic cigarettes, the risks to health are less clear and there may be evidence of a harm reduction compared to cigarettes. In this article, we discuss commonly used forms of non-cigarette tobacco products, their impacts on lung health, and relevant controversies surrounding their use.


Non-cigarette tobacco Smokeless tobacco Cigar Waterpipe Electronic cigarette 


  1. 1.
    Murin S, Hilbert J, Reilly SJ (1997) Cigaret smoking and the lung. Clin Rev Allergy Immunol 15:307–361PubMedGoogle Scholar
  2. 2.
    Burke H, Leonardi-Bee J, Hashim A, Pine-Abata H, Chen Y, Cook DG, Britton JR, McKeever TM (2012) Prenatal and passive smoke exposure and incidence of asthma and wheeze: systematic review and meta-analysis. Pediatrics 129:735–744PubMedGoogle Scholar
  3. 3.
    Stapleton M, Howard-Thompson A, George C, Hoover RM, Self TH (2011) Smoking and asthma. J Am Board Fam Med 24:313–322PubMedGoogle Scholar
  4. 4.
    Murin S, Bilello KS (2005) Respiratory tract infections: another reason not to smoke. Cleve Clin J Med 72:916–920PubMedGoogle Scholar
  5. 5.
    Nikota JK, Stampfli MR (2012) Cigarette smoke-induced inflammation and respiratory host defense: Insights from animal models. Pulm Pharmacol Ther 25:257–262PubMedGoogle Scholar
  6. 6.
    Vassallo R, Ryu JH (2008) Tobacco smoke-related diffuse lung diseases. Semin Respir Crit Care Med 29:643–650PubMedGoogle Scholar
  7. 7.
    DHHS (2010) How tobacco smoke causes disease: the biology and behavioral basis for smoking-attributable disease. ed. DHHS. DHHS, Atlanta, 704 pagesGoogle Scholar
  8. 8.
    Hoffmann D, Hoffmann I. (1998) Cigars: health effects and trends. Smoking and tobacco control monograph no. 9. Chapter 3: chemistry and toxicology. National Institutes of Health: National Cancer Institute, BethesdaGoogle Scholar
  9. 9.
    CDC (2011) Vital signs: current cigarette smoking among adults aged ≥ 18 years—United States, 2005–2010. MMWR Morb Mortal Wkly Rep 60:1207–1212Google Scholar
  10. 10.
    Giovino GA, Mirza SA, Samet JM, Gupta PC, Jarvis MJ, Bhala N, Peto R, Zatonski W, Hsia J, Morton J, Palipudi KM, Asma S, Group GC (2012) Tobacco use in 3 billion individuals from 16 countries: an analysis of nationally representative cross-sectional household surveys. Lancet 380:668–679PubMedGoogle Scholar
  11. 11.
    McMillen R, Maduka J, Winickoff J (2012) Use of emerging tobacco products in the United States. J Environ Public Health 2012:989474PubMedCentralPubMedGoogle Scholar
  12. 12.
    Nasim A, Khader Y, Blank MD, Cobb CO, Eissenberg T (2012) Trends in alternative tobacco use among light, moderate, and heavy smokers in adolescence, 1999–2009. Addict Behav 37:866–870PubMedCentralPubMedGoogle Scholar
  13. 13.
    Knishkowy B, Amitai Y (2005) Water-pipe (narghile) smoking: an emerging health risk behavior. Pediatrics 116:e113–e119PubMedGoogle Scholar
  14. 14.
    Weglicki LS, Templin TN, Rice VH, Jamil H, Hammad A (2008) Comparison of cigarette and water-pipe smoking by Arab and non-Arab-American youth. Am J Prev Med 35:334–339PubMedCentralPubMedGoogle Scholar
  15. 15.
    Mejia AB, Ling PM (2010) Tobacco industry consumer research on smokeless tobacco users and product development. Am J Public Health 100:78–87PubMedGoogle Scholar
  16. 16.
    Mejia AB, Ling PM, Glantz SA (2010) Quantifying the effects of promoting smokeless tobacco as a harm reduction strategy in the USA. Tob Control 19:297–305PubMedCentralPubMedGoogle Scholar
  17. 17.
    Phillips CV, Heavner KK (2009) Smokeless tobacco: the epidemiology and politics of harm. Biomarkers 14(Suppl 1):79–84PubMedGoogle Scholar
  18. 18.
    Hastings G, de Andrade M, Moodie C (2012) Tobacco harm reduction: the devil is in the deployment. BMJ 345:e8412PubMedGoogle Scholar
  19. 19.
    Pednekar MS, Gupta PC, Yeole BB, Hebert JR (2011) Association of tobacco habits, including bidi smoking, with overall and site-specific cancer incidence: results from the Mumbai cohort study. Cancer Causes Control 22:859–868PubMedCentralPubMedGoogle Scholar
  20. 20.
    Simpson, J (ed) (2000) Oxford English dictionary. Oxford University Press, OxfordGoogle Scholar
  21. 21.
    CDC N, SCPH. (2002) Smokeless tobacco fact sheet: In 3rd International Conference on Smokeless Tobacco. CDC, Stockholm. Accessed 29 January 2013
  22. 22.
    Coggins CR, Ballantyne M, Curvall M, Rutqvist LE (2012) The in vitro toxicology of Swedish snus. Crit Rev Toxicol 42:304–313PubMedCentralPubMedGoogle Scholar
  23. 23.
    Stepanov I, Villalta PW, Knezevich A, Jensen J, Hatsukami D, Hecht SS (2010) Analysis of 23 polycyclic aromatic hydrocarbons in smokeless tobacco by gas chromatography–mass spectrometry. Chem Res Toxicol 23:66–73PubMedCentralPubMedGoogle Scholar
  24. 24.
    WHO (2009) Global Adult Tobacco Survey (GATS): Part of the Global Tobacco Surveillance System (GTSS). Accessed 29 January 2013
  25. 25.
    Ayo-Yusuf OA, Reddy PS, van den Borne BW (2008) Association of snuff use with chronic bronchitis among South African women: implications for tobacco harm reduction. Tob Control 17:99–104PubMedGoogle Scholar
  26. 26.
    Boffetta P, Hecht S, Gray N, Gupta P, Straif K (2008) Smokeless tobacco and cancer. Lancet Oncol 9:667–675PubMedGoogle Scholar
  27. 27.
    Hearn BA, Renner CC, Ding YS, Vaughan-Watson C, Stanfill SB, Zhang L, Polzin GM, Ashley DL, Watson CH. (2013) Chemical analysis of Alaskan Iq’mik smokeless tobacco. Nicotine Tob Res Google Scholar
  28. 28.
    Stepanov I, Yershova K, Carmella S, Upadhyaya P, Hecht SS. (2013) Levels of (S)-N′-Nitrosonornicotine in U.S. Tobacco Products. Nicotine Tob Res (in press)Google Scholar
  29. 29.
    Stepanov I, Hecht SS, Ramakrishnan S, Gupta PC (2005) Tobacco-specific nitrosamines in smokeless tobacco products marketed in India. Int J Cancer 116:16–19PubMedGoogle Scholar
  30. 30.
    Arimilli S, Damratoski BE, Bombick B, Borgerding MF, Prasad GL (2012) Evaluation of cytotoxicity of different tobacco product preparations. Regul Toxicol Pharmacol 64:350–360PubMedGoogle Scholar
  31. 31.
    Lewis RS, Jack AM, Morris JW, Robert VJ, Gavilano LB, Siminszky B, Bush LP, Hayes AJ, Dewey RE (2008) RNA interference (RNAi)-induced suppression of nicotine demethylase activity reduces levels of a key carcinogen in cured tobacco leaves. Plant Biotechnol J 6:346–354PubMedGoogle Scholar
  32. 32.
    Hung RJ, McKay JD, Gaborieau V, Boffetta P, Hashibe M, Zaridze D, Mukeria A, Szeszenia-Dabrowska N, Lissowska J, Rudnai P, Fabianova E, Mates D, Bencko V, Foretova L, Janout V, Chen C, Goodman G, Field JK, Liloglou T, Xinarianos G, Cassidy A, McLaughlin J, Liu G, Narod S, Krokan HE, Skorpen F, Elvestad MB, Hveem K, Vatten L, Linseisen J, Clavel-Chapelon F, Vineis P, Bueno-de-Mesquita HB, Lund E, Martinez C, Bingham S, Rasmuson T, Hainaut P, Riboli E, Ahrens W, Benhamou S, Lagiou P, Trichopoulos D, Holcatova I, Merletti F, Kjaerheim K, Agudo A, Macfarlane G, Talamini R, Simonato L, Lowry R, Conway DI, Znaor A, Healy C, Zelenika D, Boland A, Delepine M, Foglio M, Lechner D, Matsuda F, Blanche H, Gut I, Heath S, Lathrop M, Brennan P (2008) A susceptibility locus for lung cancer maps to nicotinic acetylcholine receptor subunit genes on 15q25. Nature 452:633–637PubMedGoogle Scholar
  33. 33.
    Dygert HP (1957) Snuff-a source of pathogenic bacteria in chronic bronchitis. N Engl J Med 257:311–313PubMedGoogle Scholar
  34. 34.
    Maduka SO, Osim EE, Nneli RO, Anyabolu AE (2009) Effect of occupational exposure to local powdered tobacco (snuff) on pulmonary function in south eastern Nigerians. Niger J Physiol Sci 24:195–202PubMedGoogle Scholar
  35. 35.
    Henley SJ, Thun MJ, Connell C, Calle EE (2005) Two large prospective studies of mortality among men who use snuff or chewing tobacco (United States). Cancer Causes Control 16:347–358PubMedGoogle Scholar
  36. 36.
    Boffetta P, Aagnes B, Weiderpass E, Andersen A (2005) Smokeless tobacco use and risk of cancer of the pancreas and other organs. Int J Cancer 114:992–995PubMedGoogle Scholar
  37. 37.
    Luo J, Ye W, Zendehdel K, Adami J, Adami HO, Boffetta P, Nyren O (2007) Oral use of Swedish moist snuff (snus) and risk for cancer of the mouth, lung, and pancreas in male construction workers: a retrospective cohort study. Lancet 369:2015–2020PubMedGoogle Scholar
  38. 38.
    Rodu B, Jansson C (2004) Smokeless tobacco and oral cancer: a review of the risks and determinants. Crit Rev Oral Biol Med 15:252–263PubMedGoogle Scholar
  39. 39.
    Stepanov I, Jensen J, Hatsukami D, Hecht SS (2006) Tobacco-specific nitrosamines in new tobacco products. Nicotine Tob Res 8:309–313PubMedGoogle Scholar
  40. 40.
    Bolinder G, Alfredsson L, Englund A, de Faire U (1994) Smokeless tobacco use and increased cardiovascular mortality among Swedish construction workers. Am J Public Health 84:399–404PubMedGoogle Scholar
  41. 41.
    Roosaar A, Johansson AL, Sandborgh-Englund G, Axell T, Nyren O (2008) Cancer and mortality among users and nonusers of snus. Int J Cancer 123:168–173PubMedGoogle Scholar
  42. 42.
    Lee PN (2011) Summary of the epidemiological evidence relating snus to health. Regul Toxicol Pharmacol 59:197–214PubMedGoogle Scholar
  43. 43.
    Gartner C, Hall W (2009) The potential role of snus in tobacco harm reduction. Addiction 104:1586–1587PubMedGoogle Scholar
  44. 44.
    Lund KE, Scheffels J, McNeill A (2011) The association between use of snus and quit rates for smoking: results from seven Norwegian cross-sectional studies. Addiction 106:162–167PubMedCentralPubMedGoogle Scholar
  45. 45.
    Ramstrom L, Commentary on Lund et al (2011) Consolidating the evidence on effectiveness of snus for smoking cessation - implications for public health. Addiction 106:168–169PubMedGoogle Scholar
  46. 46.
    Henley SJ, Connell CJ, Richter P, Husten C, Pechacek T, Calle EE, Thun MJ (2007) Tobacco-related disease mortality among men who switched from cigarettes to spit tobacco. Tob Control 16:22–28PubMedGoogle Scholar
  47. 47.
    Ostenson CG, Hilding A, Grill V, Efendic S (2012) High consumption of smokeless tobacco ("snus") predicts increased risk of type 2 diabetes in a 10-year prospective study of middle-aged Swedish men. Scand J Public Health 40:730–737PubMedGoogle Scholar
  48. 48.
    Bergstrom J, Keilani H, Lundholm C, Radestad U (2006) Smokeless tobacco (snuff) use and periodontal bone loss. J Clin Periodontol 33:549–554PubMedGoogle Scholar
  49. 49.
    Rosenquist K (2005) Risk factors in oral and oropharyngeal squamous cell carcinoma: a population-based case–control study in southern Sweden. Swed Dent J Suppl: 1–66Google Scholar
  50. 50.
    Twombly R (2010) Snus use in the U.S.: reducing harm or creating it? J Natl Cancer Inst 102:1454–1456PubMedGoogle Scholar
  51. 51.
    CFTFK. (2009) The rise of cigars and cigar-smoking harms. Campaign for tobacco free kids, Washington DC. Accessed 13 February 2013
  52. 52.
    ACS. (2010) Cigar smoking: American Cancer Society, Atlanta. Accessed 13 February 2013
  53. 53.
    CDC. 2013. Smoking and tobacco use: cigars: fact sheet. Accessed 15 February 2013
  54. 54.
    Cullen J, Mowery P, Delnevo C, Allen JA, Sokol N, Byron MJ, Thornton-Bullock A (2011) Seven-year patterns in US cigar use epidemiology among young adults aged 18–25 years: a focus on race/ethnicity and brand. Am J Public Health 101:1955–1962PubMedGoogle Scholar
  55. 55.
    Jolly DH (2008) Exploring the use of little cigars by students at a historically black university. Prev Chronic Dis 5:A82PubMedCentralPubMedGoogle Scholar
  56. 56.
    Slade J. (1998). Smoking and tobacco control monograph no. 9. Chapter 7: marketing and promotion of cigars. National Institutes of Health: National Cancer Institute, BethesdaGoogle Scholar
  57. 57.
    Gerlach K, Cummings K, Hyland A, Gilpin E, Johnson M, Pierce J. (1998) Cigars: health effects and trends. Smoking and tobacco control monograph no. 9. Chapter 2: trends in cigar consumption and smoking prevalence. ed. CfD ControlGoogle Scholar
  58. 58.
    Brooks A, Gaier Larkin EM, Kishore S, Frank S (2008) Cigars, cigarettes, and adolescents. Am J Health Behav 32:640–649PubMedGoogle Scholar
  59. 59.
    Nasim A, Blank MD, Berry BM, Eissenberg T (2012) Cigar use misreporting among youth: data from the 2009 Youth Tobacco Survey. Virginia Prev Chronic Dis 9:E42Google Scholar
  60. 60.
    Burns D. (1998) Cigars: health effects and trends. Smoking and tobacco control monograph no. 9. Chapter 1: cigar smoking: overview and current state of the science. Centers for Disease Control, BethesdaGoogle Scholar
  61. 61.
    Burton HR, Dye NK, Bush LP (1992) Distribution of tobacco constituents in tobacco leaf tissue. 1. Tobacco-specific nitrosamines, nitrate, nitrite, and alkaloids. J Agric Food Chem 40:1050–1055Google Scholar
  62. 62.
    Brunnemann KD, Hoffmann D (1991) Analytical studies on tobacco-specific N-nitrosamines in tobacco and tobacco-smoke. Crit Rev Toxicol 21:235–240PubMedGoogle Scholar
  63. 63.
    Brunnemann KD, Hoffmann D (1981) Assessment of the carcinogenic N-nitrosodiethanolamine in tobacco products and tobacco-smoke. Carcinogenesis 2:1123–1127PubMedGoogle Scholar
  64. 64.
    Armitage AK, Turner DM (1970) Absorption of nicotine in cigarette and cigar smoke through the oral mucosa. Nature 226:1231–1232PubMedGoogle Scholar
  65. 65.
    Castlede CM, Cole PV (1973) Inhalation of tobacco-smoke by pipe and cigar smokers. Lancet 2:21–22Google Scholar
  66. 66.
    Sato S, Seino Y, Ohka T, Yahagi T, Nagao M, Matsushima T, Sugimura T (1977) Mutagenicity of smoke condensates from cigarettes, cigars and pipe tobacco. Cancer Lett 3:1–8PubMedGoogle Scholar
  67. 67.
    Hoffmann D, Hoffmann I (1997) The changing cigarette, 1950–1995. J Toxicol Environ Health 50:307–364PubMedGoogle Scholar
  68. 68.
    Rodriguez J, Jiang R, Johnson WC, MacKenzie BA, Smith LJ, Barr RG (2010) The association of pipe and cigar use with cotinine levels, lung function, and airflow obstruction: a cross-sectional study. Ann Intern Med 152:201–210PubMedCentralPubMedGoogle Scholar
  69. 69.
    Lange P, Nyboe J, Appleyard M, Jensen G, Schnohr P (1992) Relationship of the type of tobacco and inhalation pattern to pulmonary and total mortality. Eur Respir J 5:1111–1117PubMedGoogle Scholar
  70. 70.
    Ben-Shlomo Y, Smith GD, Shipley MJ, Marmot MG (1994) What determines mortality risk in male former cigarette smokers? Am J Public Health 84:1235–1242PubMedGoogle Scholar
  71. 71.
    Shanks T, Burns D. (1998) Cigars: health effects and trends. smoking and tobacco control monograph no. 9. Chapter 4: disease consequences of cigar smoking. National Institutes of Health: National Cancer Institute, BethesdaGoogle Scholar
  72. 72.
    Iribarren C, Tekawa IS, Sidney S, Friedman GD (1999) Effect of cigar smoking on the risk of cardiovascular disease, chronic obstructive pulmonary disease, and cancer in men. N Engl J Med 340:1773–1780PubMedGoogle Scholar
  73. 73.
    Levin ML, Goldstein H, Gerhardt PR (1950) Cancer and tobacco smoking; a preliminary report. J Am Med Assoc 143:336–338PubMedGoogle Scholar
  74. 74.
    Schrek R, Baker LA et al (1950) Tobacco smoking as an etiologic factor in disease; cancer. Cancer Res 10:49–58PubMedGoogle Scholar
  75. 75.
    Wynder EL, Graham EA (1950) Tobacco smoking as a possible etiologic factor in bronchiogenic carcinoma; a study of 684 proved cases. J Am Med Assoc 143:329–336PubMedGoogle Scholar
  76. 76.
    Sadowsky DA, Gilliam AG, Cornfield J (1953) The statistical association between smoking and carcinoma of the lung. J Natl Cancer Inst 13:1237–1258PubMedGoogle Scholar
  77. 77.
    Mills CA, Porter MM (1950) Tobacco smoking habits and cancer of the mouth and respiratory system. Cancer Res 10:539–542PubMedGoogle Scholar
  78. 78.
    Snegireff LS, Lombard OM (1959) Smoking habits of Massachusetts physicians; five-year follow-up study (1954–1959). N Engl J Med 261:603–604PubMedGoogle Scholar
  79. 79.
    Abelin T, Gsell OR (1967) Relative risk of pulmonary cancer in cigar and pipe smokers. Cancer 20:1288–1296PubMedGoogle Scholar
  80. 80.
    Hammond EC, Horn D (1958) Smoking and death rates; report on forty-four months of follow-up of 187,783 men. I Total mortality J Am Med Assoc 166:1159–1172Google Scholar
  81. 81.
    Hammond EC, Horn D (1958) Smoking and death rates: report on forty-four months of follow-up of 187,783 men. 2. Death rates by cause. J Am Med Assoc 166:1294–1308PubMedGoogle Scholar
  82. 82.
    Joly OG, Lubin JH, Caraballoso M (1983) Dark tobacco and lung cancer in Cuba. J Natl Cancer Inst 70:1033–1039PubMedGoogle Scholar
  83. 83.
    Lubin JH, Richter BS, Blot WJ (1984) Lung cancer risk with cigar and pipe use. J Natl Cancer Inst 73:377–381PubMedGoogle Scholar
  84. 84.
    Higgins IT, Mahan CM, Wynder EL (1988) Lung cancer among cigar and pipe smokers. Prev Med 17:116–128PubMedGoogle Scholar
  85. 85.
    Wald NJ, Watt HC (1997) Prospective study of effect of switching from cigarettes to pipes or cigars on mortality from three smoking related diseases. BMJ 314:1860–1863PubMedGoogle Scholar
  86. 86.
    McCormack VA, Agudo A, Dahm CC, Overvad K, Olsen A, Tjonneland A, Kaaks R, Boeing H, Manjer J, Almquist M, Hallmans G, Johansson I, Chirlaque MD, Barricarte A, Dorronsoro M, Rodriguez L, Redondo ML, Khaw KT, Wareham N, Allen N, Key T, Riboli E, Boffetta P (2010) Cigar and pipe smoking and cancer risk in the European Prospective Investigation into Cancer and Nutrition (EPIC). Int J Cancer 127:2402–2411PubMedGoogle Scholar
  87. 87.
    Shapiro JA, Jacobs EJ, Thun MJ (2000) Cigar smoking in men and risk of death from tobacco-related cancers. J Natl Cancer Inst 92:333–337PubMedGoogle Scholar
  88. 88.
    Kahn HA (1966) The Dorn study of smoking and mortality among U.S. veterans: report on eight and one-half years of observation. Natl Cancer Inst Monogr 19:1–125PubMedGoogle Scholar
  89. 89.
    Hammond EC (1966) Smoking in relation to the death rates of one million men and women. Natl Cancer Inst Monogr 19:127–204PubMedGoogle Scholar
  90. 90.
    Doll R, Peto R (1976) Mortality in relation to smoking: 20 years’ observations on male British doctors. Br Med J 2:1525–1536PubMedCentralPubMedGoogle Scholar
  91. 91.
    Carstensen JM, Pershagen G, Eklund G (1987) Mortality in relation to cigarette and pipe smoking: 16 years’ observation of 25,000 Swedish men. J Epidemiol Community Health 41:166–172PubMedGoogle Scholar
  92. 92.
    Shaper AG, Wannamethee SG, Walker M (2003) Pipe and cigar smoking and major cardiovascular events, cancer incidence and all-cause mortality in middle-aged British men. Int J Epidemiol 32:802–808PubMedGoogle Scholar
  93. 93.
    ALA. (2007) An emerging deadly trend: waterpipe tobacco use. In American Lung Association: Tobacco Policy Trend Alert. Accessed 25 February 2013
  94. 94.
    Maziak W (2011) The global epidemic of waterpipe smoking. Addict Behav 36:1–5PubMedGoogle Scholar
  95. 95.
    Akl EA, Gaddam S, Gunukula SK, Honeine R, Jaoude PA, Irani J (2010) The effects of waterpipe tobacco smoking on health outcomes: a systematic review. Int J Epidemiol 39:834–857PubMedGoogle Scholar
  96. 96.
    Warren CW, Lea V, Lee J, Jones NR, Asma S, McKenna M (2009) Change in tobacco use among 13–15 year olds between 1999 and 2008: findings from the Global Youth Tobacco Survey. Glob Health Promot 16:38–90PubMedGoogle Scholar
  97. 97.
    Anjum Q, Ahmed F, Ashfaq T (2008) Knowledge, attitude and perception of water pipe smoking (Shisha) among adolescents aged 14–19 years. J Pak Med Assoc 58:312–317PubMedGoogle Scholar
  98. 98.
    Jawaid A, Zafar AM, Rehman TU, Nazir MR, Ghafoor ZA, Afzal O, Khan JA (2008) Knowledge, attitudes and practice of university students regarding waterpipe smoking in Pakistan. Int J Tuberc Lung Dis 12:1077–1084PubMedGoogle Scholar
  99. 99.
    Carroll T, Poder N, Perusco A (2008) Is concern about waterpipe tobacco smoking warranted? Aust N Z J Public Health 32:181–182PubMedGoogle Scholar
  100. 100.
    Parna K, Usin J, Ringmets I (2008) Cigarette and waterpipe smoking among adolescents in Estonia: HBSC survey results, 1994–2006. BMC Publ Health 8:392Google Scholar
  101. 101.
    Jensen PD, Cortes R, Engholm G, Kremers S, Gislum M (2010) Waterpipe use predicts progression to regular cigarette smoking among Danish youth. Subst Use Misuse 45:1245–1261PubMedGoogle Scholar
  102. 102.
    Barnett TE, Curbow BA, Weitz JR, Johnson TM, Smith-Simone SY (2009) Water pipe tobacco smoking among middle and high school students. Am J Public Health 99:2014–2019PubMedGoogle Scholar
  103. 103.
    Chan WC, Leatherdale ST, Burkhalter R, Ahmed R (2011) Bidi and hookah use among Canadian youth: an examination of data from the 2006 Canadian Youth Smoking Survey. J Adolesc Health 49:102–104PubMedGoogle Scholar
  104. 104.
    Primack BA, Walsh M, Bryce C, Eissenberg T (2009) Water-pipe tobacco smoking among middle and high school students in Arizona. Pediatrics 123:e282–e288PubMedCentralPubMedGoogle Scholar
  105. 105.
    Jordan HM, Delnevo CD (2010) Emerging tobacco products: hookah use among New Jersey youth. Prev Med 51:394–396PubMedGoogle Scholar
  106. 106.
    Azab M, Khabour OF, Alkaraki AK, Eissenberg T, Alzoubi KH, Primack BA (2010) Water pipe tobacco smoking among university students in Jordan. Nicotine Tob Res 12:606–612PubMedGoogle Scholar
  107. 107.
    Jackson D, Aveyard P. (2008). Waterpipe smoking in students: prevalence, risk factors, symptoms of addiction, and smoke intake. Evidence from one British university. BMC Public Health 8: 174Google Scholar
  108. 108.
    Cobb C, Ward KD, Maziak W, Shihadeh AL, Eissenberg T (2010) Waterpipe tobacco smoking: an emerging health crisis in the United States. Am J Health Behav 34:275–285PubMedCentralPubMedGoogle Scholar
  109. 109.
    Primack BA, Fertman CI, Rice KR, Adachi-Mejia AM, Fine MJ (2010) Waterpipe and cigarette smoking among college athletes in the United States. J Adolesc Health 46:45–51PubMedCentralPubMedGoogle Scholar
  110. 110.
    Cobb CO, Khader Y, Nasim A, Eissenberg T (2012) A multiyear survey of waterpipe and cigarette smoking on a US university campus. J Am Coll Health 60:521–527PubMedGoogle Scholar
  111. 111.
    Grekin ER, Ayna D (2012) Waterpipe smoking among college students in the United States: a review of the literature. J Am Coll Health 60:244–249PubMedGoogle Scholar
  112. 112.
    Neergaard J, Singh P, Job J, Montgomery S (2007) Waterpipe smoking and nicotine exposure: a review of the current evidence. Nicotine Tob Res 9:987–994PubMedGoogle Scholar
  113. 113.
    Chan A, Murin S (2011) Up in smoke: the fallacy of the harmless Hookah. Chest 139:737–738PubMedGoogle Scholar
  114. 114.
    Smith-Simone S, Maziak W, Ward KD, Eissenberg T (2008) Waterpipe tobacco smoking: knowledge, attitudes, beliefs, and behavior in two U.S. samples. Nicotine Tob Res 10:393–398PubMedCentralPubMedGoogle Scholar
  115. 115.
    Primack BA, Sidani J, Agarwal AA, Shadel WG, Donny EC, Eissenberg TE (2008) Prevalence of and associations with waterpipe tobacco smoking among U.S. university students. Ann Behav Med 36:81–86PubMedCentralPubMedGoogle Scholar
  116. 116.
    Ahmed B, Jacob P 3rd, Allen F, Benowitz N (2011) Attitudes and practices of hookah smokers in the San Francisco Bay Area. J Psychoactive Drugs 43:146–152PubMedGoogle Scholar
  117. 117.
    Wray RJ, Jupka K, Berman S, Zellin S, Vijaykumar S (2012) Young adults’ perceptions about established and emerging tobacco products: results from eight focus groups. Nicotine Tob Res 14:184–190PubMedGoogle Scholar
  118. 118.
    Sutfin EL, McCoy TP, Reboussin BA, Wagoner KG, Spangler J, Wolfson M (2011) Prevalence and correlates of waterpipe tobacco smoking by college students in North Carolina. Drug Alcohol Depend 115:131–136PubMedCentralPubMedGoogle Scholar
  119. 119.
    Shihadeh A (2003) Investigation of mainstream smoke aerosol of the argileh water pipe. Food Chem Toxicol 41:143–152PubMedGoogle Scholar
  120. 120.
    Shihadeh A, Saleh R (2005) Polycyclic aromatic hydrocarbons, carbon monoxide, "tar", and nicotine in the mainstream smoke aerosol of the narghile water pipe. Food Chem Toxicol 43:655–661PubMedGoogle Scholar
  121. 121.
    Fromme H, Dietrich S, Heitmann D, Dressel H, Diemer J, Schulz T, Jorres RA, Berlin K, Volkel W (2009) Indoor air contamination during a waterpipe (narghile) smoking session. Food Chem Toxicol 47:1636–1641PubMedGoogle Scholar
  122. 122.
    Daher N, Saleh R, Jaroudi E, Sheheitli H, Badr T, Sepetdjian E, Al Rashidi M, Saliba N, Shihadeh A (2010) Comparison of carcinogen, carbon monoxide, and ultrafine particle emissions from narghile waterpipe and cigarette smoking: Sidestream smoke measurements and assessment of second-hand smoke emission factors. Atmos Environ 44:8–14PubMedCentralGoogle Scholar
  123. 123.
    Sepetdjian E, Saliba N, Shihadeh A (2010) Carcinogenic PAH in waterpipe charcoal products. Food Chem Toxicol 48:3242–3245PubMedCentralPubMedGoogle Scholar
  124. 124.
    Cobb CO, Vansickel AR, Blank MD, Jentink K, Travers MJ, Eissenberg T. (2012). Indoor air quality in Virginia waterpipe cafes. Tob Control Google Scholar
  125. 125.
    Maziak W, Rastam S, Ibrahim I, Ward KD, Eissenberg T (2008) Waterpipe-associated particulate matter emissions. Nicotine Tob Res 10:519–523PubMedGoogle Scholar
  126. 126.
    Maziak W, Rastam S, Shihadeh AL, Bazzi A, Ibrahim I, Zaatari GS, Ward KD, Eissenberg T (2011) Nicotine exposure in daily waterpipe smokers and its relation to puff topography. Addict Behav 36:397–399PubMedCentralPubMedGoogle Scholar
  127. 127.
    Jacob P 3rd, Abu Raddaha AH, Dempsey D, Havel C, Peng M, Yu L, Benowitz NL (2011) Nicotine, carbon monoxide, and carcinogen exposure after a single use of a water pipe. Cancer Epidemiol Biomarkers Prev 20:2345–2353PubMedCentralPubMedGoogle Scholar
  128. 128.
    Maziak W, Rastam S, Ibrahim I, Ward KD, Shihadeh A, Eissenberg T (2009) CO exposure, puff topography, and subjective effects in waterpipe tobacco smokers. Nicotine Tob Res 11:806–811PubMedGoogle Scholar
  129. 129.
    Eissenberg T, Shihadeh A (2009) Waterpipe tobacco and cigarette smoking: direct comparison of toxicant exposure. Am J Prev Med 37:518–523PubMedCentralPubMedGoogle Scholar
  130. 130.
    Monzer B, Sepetdjian E, Saliba N, Shihadeh A (2008) Charcoal emissions as a source of CO and carcinogenic PAH in mainstream narghile waterpipe smoke. Food Chem Toxicol 46:2991–2995PubMedGoogle Scholar
  131. 131.
    Yadav JS, Thakur S (2000) Genetic risk assessment in hookah smokers. Cytobios 101:101–113PubMedGoogle Scholar
  132. 132.
    El-Setouhy M, Loffredo CA, Radwan G, Abdel Rahman R, Mahfouz E, Israel E, Mohamed MK, Ayyad SB (2008) Genotoxic effects of waterpipe smoking on the buccal mucosa cells. Mutat Res 655:36–40PubMedCentralPubMedGoogle Scholar
  133. 133.
    Khabour OF, Alsatari ES, Azab M, Alzoubi KH, Sadiq MF (2011) Assessment of genotoxicity of waterpipe and cigarette smoking in lymphocytes using the sister-chromatid exchange assay: a comparative study. Environ Mol Mutagen 52:224–228PubMedGoogle Scholar
  134. 134.
    Rammah M, Dandachi F, Salman R, Shihadeh A, El-Sabban M (2012) In vitro cytotoxicity and mutagenicity of mainstream waterpipe smoke and its functional consequences on alveolar type II derived cells. Toxicol Lett 211:220–231PubMedCentralPubMedGoogle Scholar
  135. 135.
    Cobb CO, Sahmarani K, Eissenberg T, Shihadeh A (2012) Acute toxicant exposure and cardiac autonomic dysfunction from smoking a single narghile waterpipe with tobacco and with a "healthy" tobacco-free alternative. Toxicol Lett 215:70–75PubMedCentralPubMedGoogle Scholar
  136. 136.
    Hakim F, Hellou E, Goldbart A, Katz R, Bentur Y, Bentur L (2011) The acute effects of water-pipe smoking on the cardiorespiratory system. Chest 139:775–781PubMedGoogle Scholar
  137. 137.
    Raad D, Gaddam S, Schunemann HJ, Irani J, Abou Jaoude P, Honeine R, Akl EA (2011) Effects of water-pipe smoking on lung function: a systematic review and meta-analysis. Chest 139:764–774PubMedGoogle Scholar
  138. 138.
    Tageldin MA, Nafti S, Khan JA, Nejjari C, Beji M, Mahboub B, Obeidat NM, Uzaslan E, Sayiner A, Wali S, Rashid N, El Hasnaoui A, Group BS (2012) Distribution of COPD-related symptoms in the Middle East and North Africa: results of the BREATHE study. Respir Med 106(Suppl 2):S25–S32PubMedGoogle Scholar
  139. 139.
    Salameh P, Waked M, Khoury F, Akiki Z, Nasser Z, Abou Abbass L, Dramaix M, Chronic Bronchitis Study G (2012) Waterpipe smoking and dependence are associated with chronic bronchitis: a case–control study in Lebanon. East Mediterr Health J 18:996–1004Google Scholar
  140. 140.
    Nafae A, Misra SP, Dhar SN, Shah SN (1973) Bronchogenic carcinoma in Kashmir Valley. Indian J Chest Dis 15:285–295PubMedGoogle Scholar
  141. 141.
    Koul PA, Hajni MR, Sheikh MA, Khan UH, Shah A, Khan Y, Ahangar AG, Tasleem RA (2011) Hookah smoking and lung cancer in the Kashmir valley of the Indian subcontinent. Asian Pac J Cancer Prev 12:519–524PubMedGoogle Scholar
  142. 142.
    Maziak W (2013) The waterpipe: an emerging global risk for cancer. Cancer Epidemiol 37:1–4PubMedGoogle Scholar
  143. 143.
    Steentoft J, Wittendorf J, Andersen JR (2006) Tuberculosis and water pipes as source of infection. Ugeskr Laeger 168:904–907PubMedGoogle Scholar
  144. 144.
    Szyper-Kravitz M, Lang R, Manor Y, Lahav M (2001) Early invasive pulmonary aspergillosis in a leukemia patient linked to aspergillus contaminated marijuana smoking. Leuk Lymphoma 42:1433–1437PubMedGoogle Scholar
  145. 145.
    Breland AB, Kleykamp BA, Eissenberg T (2006) Clinical laboratory evaluation of potential reduced exposure products for smokers. Nicotine Tob Res 8:727–738PubMedGoogle Scholar
  146. 146.
    Lipkus IM, Eissenberg T, Schwartz-Bloom RD, Prokhorov AV, Levy J (2011) Affecting perceptions of harm and addiction among college waterpipe tobacco smokers. Nicotine Tob Res 13:599–610PubMedGoogle Scholar
  147. 147.
    Cobb NK, Abrams DB (2011) E-cigarette or drug-delivery device? Regulating novel nicotine products. N Engl J Med 365:193–195PubMedGoogle Scholar
  148. 148.
    Eissenberg T (2010) Electronic nicotine delivery devices: ineffective nicotine delivery and craving suppression after acute administration. Tob Control 19:87–88PubMedCentralPubMedGoogle Scholar
  149. 149.
    Bullen C, McRobbie H, Thornley S, Glover M, Lin R, Laugesen M (2010) Effect of an electronic nicotine delivery device (e cigarette) on desire to smoke and withdrawal, user preferences and nicotine delivery: randomised cross-over trial. Tob Control 19:98–103PubMedGoogle Scholar
  150. 150.
    Etter JF, Bullen C (2011) Electronic cigarette: users profile, utilization, satisfaction and perceived efficacy. Addiction 106:2017–2028PubMedGoogle Scholar
  151. 151.
    Polosa R, Caponnetto P, Morjaria JB, Papale G, Campagna D, Russo C (2011) Effect of an electronic nicotine delivery device (e-Cigarette) on smoking reduction and cessation: a prospective 6-month pilot study. BMC Publ Health 11:786Google Scholar
  152. 152.
    Choi K, Forster J (2013) Characteristics associated with awareness, perceptions, and use of electronic nicotine delivery systems among young US Midwestern adults. Am J Public Health 103:556–561PubMedGoogle Scholar
  153. 153.
    Pepper JK, Reiter PL, McRee AL, Cameron LD, Gilkey MB, Brewer NT (2013) Adolescent males’ awareness of and willingness to try electronic cigarettes. The Journal of adolescent health : official publication of the Society for Adolescent Medicine 52:144–150Google Scholar
  154. 154.
    Flouris AD, Chorti MS, Poulianiti KP, Jamurtas AZ, Kostikas K, Tzatzarakis MN, Wallace Hayes A, Tsatsaki AM, Koutedakis Y (2013) Acute impact of active and passive electronic cigarette smoking on serum cotinine and lung function. Inhal Toxicol 25:91–101PubMedGoogle Scholar
  155. 155.
    Flouris AD, Poulianiti KP, Chorti MS, Jamurtas AZ, Kouretas D, Owolabi EO, Tzatzarakis MN, Tsatsakis AM, Koutedakis Y (2012) Acute effects of electronic and tobacco cigarette smoking on complete blood count. Food and chemical toxicology : an international journal published for the British Industrial Biological Research Association 50:3600–3603Google Scholar
  156. 156.
    Pellegrino RM, Tinghino B, Mangiaracina G, Marani A, Vitali M, Protano C, Osborn JF, Cattaruzza MS (2012) Electronic cigarettes: an evaluation of exposure to chemicals and fine particulate matter (PM). Annali di igiene : medicina preventiva e di comunita 24:279–288Google Scholar
  157. 157.
    McAuley TR, Hopke PK, Zhao J, Babaian S (2012) Comparison of the effects of e-cigarette vapor and cigarette smoke on indoor air quality. Inhal Toxicol 24:850–857PubMedGoogle Scholar
  158. 158.
    Vardavas CI, Anagnostopoulos N, Kougias M, Evangelopoulou V, Connolly GN, Behrakis PK (2012) Short-term pulmonary effects of using an electronic cigarette: impact on respiratory flow resistance, impedance, and exhaled nitric oxide. Chest 141:1400–1406PubMedGoogle Scholar
  159. 159.
    DHHS. (2011). Regulation of E-cigarettes and other tobacco products. ed. FDA. Accessed 25 February 2013
  160. 160.
    King BA, Alam S, Promoff G, Arrazola R, Dube SR. (2013). Awareness and ever use of electronic cigarettes among U.S. adults, (2010–2011). Nicotine & Tobacco Research: Official Journal of the Society for Research on Nicotine and TobaccoGoogle Scholar
  161. 161.
    Pepper JK, Reiter PL, McRee AL, Cameron LD, Gilkey MB, Brewer NT (2013) Adolescent males’ awareness of and willingness to try electronic cigarettes. J Adolesc Health 52:144–150PubMedCentralPubMedGoogle Scholar

Copyright information

© Springer Science+Business Media New York 2013

Authors and Affiliations

  • Michael Schivo
    • 1
  • Mark V. Avdalovic
    • 1
    • 2
  • Susan Murin
    • 1
    • 2
  1. 1.Department of Internal Medicine, Division of Pulmonary, Critical Care, and Sleep MedicineUniversity of California, Davis, School of MedicineSacramentoUSA
  2. 2.Department of MedicineVeterans Affairs Northern California Healthcare SystemMatherUSA

Personalised recommendations